Student's Last Name (required)
Student's First Name (required)
Student's Age (required)
Student's DOB (required)

---MaleFemale

Student's Place of Birth (required)
Student's Address (required)
City (required) State (required) Zip (required)
Your Email (required)
Subject
Your Message
School Last Address City
Grade Last Completed (required) Grade Entering in August (required)
Has Student have Full Time School before? If so when, where? Has Student ever repeated a grade or had serious academic problems in school?
What are your goals/ reasons for enrolling (ren) your child at NUIA?

Medical:
Does your child have any medical problems of which the school should be aware?
EpilepsieDiabetesAllergiesAsthma,Hearing,Vision,Speech,Heart Disease,Other- Please explain

Please use the space below to provide any other information that might be helpful about the student

Family Information
Father:
Father's (or Guardian's) Last Name: (required)
Father's First Name: (required) Title:
SS#:(required)

Address: (required) Input Address/ Student's Address:
City: (required)
State: (required)
Zip code: (required)
Dad's Cell/ Phone: (required)
Employer: Occupation:

Mother:
Mother's (or Guardian's) Last Name: (required)
Mother's First Name: (required) Title:
SS#:(required)
Address: (required) Input Address/ Student's and Dad's Address:
City: (required)
State: (required)
Zip code: (required)

Mom's Cell/ Phone: (required)
Employer: Occupation:
Parents' Marital Status: MarriedSeparatedDivorcedWidowed

Emergency Contact:
Full Name: (required)
Relationship: (required)
Phone: (required)
Address: (required)
City: (required)
State: (required)
Zip Code: (required)

Terms and Conditions
I (we) hereby affirm that, to the best of my (our) knowledge, all statements made herein are true and complete. I (we) understand that this is only an application for enrollment, it is not a contract. I (we) also understand that NUIA will review the information and its supporting documents before a final decision is made. I (we) further understand that admission into Nur-Ul-Islam Academy is confident upon the completeness and accuracy of this application and it abides by all school policies including payment policies. Parents are responsible for providing the school with updated emergency contact persons, and/ or telephone numbers. These include, but not limited to medical changes in medical information, address, phone number and guardianship.
I do not accept the Terms and ConditionsI accept these Terms and Conditions

Father's Guardian's Name: (required) Mother's Guardian's Name:
Date: (required)