STUDENT REGISTRATION FORM

2021-2022

Please complete and review each section of this form. All completed Registration Forms should be
submitted to:

ATT: Sister Shirina Ally

7723 Timber River Circle
Orlando, FL 32807
PLEASE NOTE that, to attend Madrasah Rahmaniyyah, your child must be 4 years old by
September 30, 2021, to register for our Pre – K Class, and the eldest 12 years of age.

For more information:

Contact sister Shirina.

(407) 574-2155 {Leave a message or text (321) 948-5436

Email: sherry_ally@yahoo.com

Student Name(s) Date of Birth/Age Gender (M/F)

1

4
 TELL USMOTHER’S
ABOUT YOUR CHILD(REN)
INFORMATION
If you have more than one child attending, please provide theCountry
information on each child. This information will help
Name:
us get to know your child better and keep us informed of matters we should be aware of.
of Birth:
Does
Phoneyour
# child have any Phone #
allergies
(Cell): (food or other)? (Home):
Does your child have any
Email:
medical conditions?
What motivates your child?
Address:
What upsets
Are you yourinchild?
interested volunteering?  Yes  No
If Yes, what type of skills/tasks are you able to assist in:
Is there anything else we
should know about your child?
FATHER’S INFORMATION
Country
Name:
of Birth:
Phone #
Cell #:
(Home):

Email:

Address:

Are you interested in volunteering?  Yes  No

If Yes, what type of skills/tasks are you able to assist in:

EMERGENCY CONTACT INFORMATION

Name:
Phone # Phone #
(Cell): (Home):
Relationship
to Student:
IMPORTANT GUIDELINES AND INFORMATION

1. The Madrasah Rahmaniyyah classes are held Monday through Thursday from 5 pm to 7 pm. Parents are
required to bring their children on time at 5 p.m. and pick them up on time at 7 p.m. If a student is picked up after
7:00 p.m., a late fee of $1 per minute will be charged to the parent.

2. The student fee to attend Madrasah Rahmaniyyah is $25.00 per child/per month. Student fees are considered
late if received after the 5 th day of each month. If payment is received after the 5 th day of each month, a late fee
of $5 per day will be charged to the parent.

3. There is a deposit of $25.00 per a child payable at the time of registration which will be used for the last
payment before the school year ends in May. (New)

4. There is a one-time $10 snack fee per family. (To be paid when we go back to the masjid )

5. Parents and students are required to read, understand, and follow Madrasah Rahmaniyyah policies and
discipline guidelines given at the time of registration, (this year it will be emailed). All policies will be strictly
implemented.

ACKNOWLDGEMENT

I, __________________________, guardian of the child(ren) mentioned above, have received the policies
handbook, and agree to sign, date, and return the acknowledgement on the First Day of Rahmaniyyah. The
information entered in this form is accurate and completed to the best of my knowledge.

I release Madrasah Rahmaniyyah, its staff, and the Islamic Society of Central Florida from any claims arising
out of this Registration Form, and/or my child(ren)’s attendance at Madrasah Rahmaniyyah, including claims of
negligence, claims for personal injury, property damage, and economic loss.

Parent Signature _______________________________________

Date _________________________________
 Tell us About Your Child

Does your child have any medical conditions?

………………………………………………………………………………………………………………………

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Does your child have any allergies? (Food allergies, material, etc)

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What motivates your child?

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What upsets your child?

………………………………………………………………………………………………………………………

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Are there any special concerns you have about your child attending elementary school?

………………………………………………………………………………………………………………………

………….………………………………………………………………………………………………………...…

………….………………………………………………………………………………………………………...…

Is there anything else we should know about your child?

………………………………………………………………………………………………………………………

………….………………………………………………………………………………………………………...…
 I have provided the above information with all honesty to my best knowledge.

Parent/Guardian signature: _____________________________________

Date: _________________

Contact Person

Sister Shirina (407-574-2155) please leave a message or

Text (321-948-5436)

Email: sherry_ally@yahoo.com

Mail To:

7723 Timber River Circle

Orlando, FL 32807