All Student Registration - Charlotte Islamic Academy

Parent/Legal Guardian Information

Who is completing this form? *

Name of legal guardian who is completing this form *

First

Last

Legal Guardian's Email Address *

Legal Guardian's Cell Phone *

Legal Guardian's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Legal Guardian's Employer *

Legal Guardian's Business Phone *

Preferred contact method *

Father Name : *

First

Last

Father's Email *

Father's Cell Phone *

Father's Employer *

Father's Business Phone *

Father - Preferred contact method *

Mother Name : *

First

Last

Mother's Email *

Mother's Cell Phone *

Mother's Employer *

Mother's Business Phone *

Mother - Preferred contact method *

Who is the preferred contact person? *

Other Contact's Name & Phone Number *

SMS Messaging Authorization (Optional)

Would you like to receive text messages from the school? Please select your service provider below *

AT&T
Sprint
Verizon
Cricket
Other, please specify
No, I do not wish to receive text alerts from the school

Other Service Provider Name *

I give permission to the school to send school updates as text messages - Signature required below *

Parent/Legal Guardian Information (continued)

Any additional Parent(s) or Step-Parent(s) (ONLY) Email or Phone? *

Yes, 1 More Parent/Step-Parent
Yes, 2 More Parents/Step-Parents
No
I'll provide later

Choose one option

Additional Parent/Step-Parent Name *

First

Last

Additional Parent/Step-Parent Phone Number *

Additional Parent/Step-Parent Email *

Additional Parent/Step-Parent Address *

Address Line 1

Address Line 2

City

State

Zip Code

Should we store the above-named "Additional Parent/Step-Parent" for all or some of the children?

Please list the names of the children for which you would like this "Additional Parent/Step-Parent" information to be stored under. *

Additional Parent/Step-Parent 2 Name *

First

Last

Additional Parent/Step-Parent 2 Phone Number *

Additional Parent/Step-Parent 2 Email *

Additional Parent/Step-Parent 2 Address *

Address Line 1

Address Line 2

City

State

Zip Code

Should we store the above-named "Additional Parent/Step-Parent 2" for all or some of the children? *

Please list the names of the children for which you would like this "Additional Parent/Step-Parent 2" information to be stored under. *

Student(s) primarily lives with? (Needed for Jupiter grades) *

Relationship to the child(ren) *

Registration Fees Due

PLEASE NOTE: All registration fees are to be paid before completing this application. Registration fees are as follows:

1 student = $100
2 students =$175
3+ students = $250

If you are enrolling 3 or more children the rate remains the same $250 for all children unlimited.

Total number of children to enroll. *

Student Information

Primary Residence Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student's Name *

First

Last

Student's Date of Birth *

Student's Gender *

Student's Place Of Birth (City, State, Country) *

Student's US Citizenship? *

Yes
No
Other

Student's Other Citizenship? *

I am enrolling my child for grade.... *

Student 1 Information

First Student's Name 1 of 2 *

First

Last

First Student's Date of Birth *

First Student's Gender *

First Student's Place Of Birth (City, State, Country) *

First Student's US Citizenship? *

Yes
No
Other

First Student's Other Citizenship? *

I am enrolling child 1 for grade.... *

Student 2 Information

Second Student's Name 2 of 2 *

First

Last

Second Student's Grade: *

Second Student's Date of Birth *

Second Student's Gender *

Second Student's Place Of Birth (City, State, Country) *

Second Student's US Citizenship? *

Yes
No
Other

Second Student's Other Citizenship? *

I am enrolling child 2 for grade.... *

Student 1 Information

First Student's Name 1 of 3 *

First

Last

First Student's Grade: *

First Student's Date of Birth *

First Student's Gender *

First Student's Place Of Birth (City, State, Country) *

First Student's US Citizenship? *

Yes
No
Other

First Student's Other Citizenship? *

I am enrolling child 1 for grade.... *

Student 2 Information

Second Student's Name 2 of 3 *

First

Last

Second Student's Grade: *

Second Student's Date of Birth *

Second Student's Gender *

Second Student's Place Of Birth (City, State, Country) *

Second Student's US Citizenship? *

Yes
No
Other

Second Student's Other Citizenship? *

I am enrolling child 2 for grade.... *

Student 3 Information

Third Student's Name 2 of 3 *

First

Last

Third Student's Grade: *

Third Student's Date of Birth *

Third Student's Gender *

Third Student's Place Of Birth (City, State, Country) *

Third Student's US Citizenship? *

Yes
No
Other

Third Student's Other Citizenship? *

I am enrolling child 3 for grade.... *

Family Language

English is the PRIMARY language spoken at home? *

What other language, other than English, is used in the home? *

Is the other language, you've listed, spoken more often or less often than English? *

More Often
Less Often
Neither More or Less

What language is spoken by the adults in the home? *

What is the first language your child(ren) learned to speak? *

What date (month and year) was your child first enrolled in any U.S. school (Private or Public, but not PreK)? Indicate if the child left the U.S. for a school year(s): *

What date (month and year) was your children first enrolled in any U.S. school (Private or Public, but not PreK)? Indicate of your children left the U.S. for a school year(s): *

How many years has your child(ren) been in school in the US? *

Documentation Upload

You may upload copies of the following records in pdf format only. If you are unable to upload these documents in .pdf format you may drop them off at the main office.

Please note all original documents must be delivered in person to the Office Manager for authentication before your child(ren) can be approved for enrollment. Documents uploaded here are only for preliminary reviewing.

Birth Certificate *

Click or drag files to this area to upload. You can upload up to 7 files.

Immunization Records *

Click or drag files to this area to upload. You can upload up to 7 files.

Student Release (Authorized To Sign Out)

Indicate the primary person, other than parents, who is authorized to sign your child(ren) out of school. Photo identification required for student pickup. *

Please provide name, relationship and phone number during school hours for listed emergency contacts

Indicate the secondary person, other than parents, who is authorized to sign your child(ren) out of school. Photo identification required for student pickup. *

Please provide name, relationship and phone number during school hours for listed emergency contacts

Indicate the tertiary person, other than parents, who is authorized to sign your child(ren) out of school. Photo identification required for student pickup. *

Please provide name, relationship and phone number during school hours for listed emergency contacts

Signature Required - I, the undersigned, give Charlotte Islamic Academy permission to release my child(ren) to any of the 3 individuals named above. If for any reason these individuals are no longer authorized to sign out my child(ren) from school I will notify Charlotte Islamic Academy within 24 hours of this change in authority.