Evening Madrasa

Step 1 of 2 – Student Information

Student Information

Class Format(Required)

Evening Madrasah

Evening Hifz

Adult Quran Class

Please select which format you are enrolling for.

Students Name(Required)

First Middle Last

Date of Birth(Required)

Gender(Required)

Male

Female

Home Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Islamic Study(Required)

Basic

Intermediate

Advanced

None

OHIP Number(Required)

Not applicable for adults.

OHIP Expiry

Name of Family Doctor(Required)

First Last

Not applicable for adults.

Family Doctor Phone(Required)

Not applicable for adults.

Parent/Guardian Information

Adult students please provide emergency contact information.

Father's Name(Required)

First Last

Father's Email(Required)

Father's Work Phone

Father's Cell Phone(Required)

Mother's Name(Required)

First Last

Mother's Email(Required)

Mother's Work Phone

Mother's Cell Phone(Required)

Emergency Contact Name(Required)

First Last

Please list someone other than the parents/guardians.

Emergency Contact Phone(Required)

Evening Madrasah(Required)

Price:

Registration Fee per month

Evening Hifz(Required)

Price:

Registration Fee per month

Adult Quran Class(Required)

Price:

Registration Fee per month

Billing Info(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card(Required)

Student Information

Parent/Guardian Information

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