Registration Form – Institute of Islamic Learning in Metroplex

Basic Information

1st Student Details

1. Student Full Name

1. Student Cell Phone

1. Student DOB

1. Student Gender

Male
Female

If More Children's to Add (Click On Checkbox)

More Children's

2nd Student Details

3rd Student Details

4th Student Details

5th Student Details

New Student

Yes
No

Student Address

Address Line 1

City

State

Zip Code

Parent's Information

Parent Email

Father Full Name

First

Last

Father Phone Number

Mother Full Name

First

Last

Mother Phone Number

Will father participate in Parent / Teacher organization

Yes
No

Will mother participate in Parent / Teacher organization

Yes
No

Health Related Information

Does your child have any medical or food allergies? If so please explain all known allergies.

Pediatrician / Doctor's Name

First

Last

Pediatrician / Doctor's Phone

Emergency Contact Name (if different than parents):

First

Last

Emergency Contact Phone (if different than parents):

Payment Information

Fall Semester Fee (Tuition + Lunch + One Time Registration)

Are you current IILM Sunday School Teacher:

Yes

* Teachers to get additional discount on child fees

Teacher Child Fall Semester Fee (Tuition + Lunch + One Time Registration)

* Teacher Child Discount Information: Additional 25% Off Total Fee