Witton Islamic Centre

Child's Full Name *

Date of Birth *

Gender *

Male Female

Previous Madrasah(s)

Siblings currently enrolled or enrolling? *

Yes No

Parent / Guardian Name *

Relationship to Child *

Emergency Contact Number *

Alternative Contact Number

Email Address *

Child's Home Address *

Postcode *

Parent's Address (if different)

Does your child have any allergies or health conditions? *

No Yes

Does your child take any regular medication? *

No Yes

GP Name

GP Practice

GP Phone Number

Other Notes / Medical Conditions

Qa'idah Reading Level *

Beginner Intermediate Advanced

Qur'an Reading Level *

Beginner Intermediate Advanced

Hifdh Amount

Consent for photos/videos of your child to be used for Madrasah social media *

Yes No

Madrasah As-Salafiyah Registration