Southend Mosque Madrasa Registration

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Asalamualaikum. Please fill in all the details on this form, to add your child(ren) into our waiting list

* denotes required field
Autofill: Father Mother Brother Sister
If you already have an account and a password, you can skip this and leave it blank. Otherwise you should set your password now to login to the parent portal now.

Students

 Student #1:
 Surname:
D.O.B:
Gender:
 Email:
*Enroll:
Monday/Wednesday/Thursday 5PM-7PM
Add medical info/notes

Contacts

You are the primary contact. You can add more contacts below.
Additional Contact #1
 Contact Name:
 Email:
 Tel.:
 Parent Portal Password:
 Confirm:
 Mobile:
 Alt. Mob.:
Relation:
Type: