Jamia-tul-madina USA

Student Information

First name:

Middle name (if any)

Last Name:

Date of Birth:

Right to Abode: Yes No

Home Address:

Ethnicity:

Nationality:

Place Of Birth:

Phone:

Email:

Permanent USA Residence since:

Residency after Admission: Off-Campus Hostel Home

Your spoken language(s):

Parent/Guardian Information

First name:

Middle name:

Last name:

Date of Birth:

Place Of Birth:

Home Address:

Nationality:

Occupation:

Relation to Applicant:

Phone:

Email:

Academic Information

School name:

Type of School: Public Private Home-school Other

Start Date:

Date of Graduation:

Are you Currently Enrolled in School/College? Yes No

If Yes, what school year?

Provider School/College Address

Attached Document:

Islamic Education Information

Name of Madarsa last attended:

Have you completed reciting (Nazra) the whole Quran? Yes No

If No, how much did you complete?

Type of Madarsa: Quran Class Sunday School Alim Class Other

Have you completely memorized the Quran? Yes No

If Yes, what year did you finish in?

Address:

Have you memorized (Hifz) any part of the Quran? Yes No

If Yes, how much did you memorize?

Phone:

Have you joined an Alim course before? Yes No

Write down the books you have read or the level you achieved

Duration attended:

Emergency Contact Information

Emergency Contact #1:

Emergency Contact #2:

Emergency Contact #3

Discipline Information

If you answered Yes to any question, please provide full details, an explanation and approximate date for each incident.
Other than traffic offences, has the applicant been convicted of any misdemeanor or felony?	Yes No
Has the applicant had any involvement with a terrorist or anarchic group?	Yes No
Has the applicant ever been placed on probation, suspended, removed or expelled from any previous schools?	Yes No
Please attach your response to the end of the application.

Medical Information

Does the applicant have any serious illness or injuries or has had in the past?	Yes No
If Yes, please provide full details
Does the applicant have any known allergies?	Yes No
If Yes, please provide full details
Does the applicant have any medical condition such as Cancer, Diabetes, or Blood Pressure etc?	Yes No
If Yes, please provide full details including details of prescribed medication, frequency etc.
Does the applicant have any special needs?	Yes No
If Yes, please provide full details
Does the applicant have Health Insurance?	Yes No
Insurance Company’s Name: Insurance Policy Number

Authorization

Please provide all the required documents listed below with your Application Form completed in full. Applications will only be processed once we have received all documents.

1. Copy of Birth Certificate

4. Letter of Recommendation from Nigran of Dawat-e-Islami for city

2. Copy of Valid Passport or Permanent Resident Card

5. Two recent Passport Size photo’s

3. High School Diploma and Transcript (School Report if student is still in High School)

6. Character reference letter

I understand that I may be recorded on the CCTV for safety and security purposes.

I understand that I may be photographed and/or videoed for track learning, displays, website, publications and electronic media

I confirm that all information in this application (including any supplemental information) isfactually true and honestly presented.

Signature of Applicant
______________________

Print Name of Applicant
______________________

Date
______________________

Signature of Parent/Guardian
______________________

Print Name of Parent/Guardian
______________________

Date
______________________

I accept terms and condition