Southend Mosque Madrasa Registration

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

* denotes required field

*Your name: (Parent/Guardian)

*Surname:

*Relation to student: Autofill: Father Mother Brother Sister

Type:

*Your email:

*Confirm email:

Parent Portal Password:

Confirm password:

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.

Telephone:

*Mobile:

*Address: *Postcode:

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:

Primary Contact? This means the contact will receive emails related to the student. The contact will also see the student on the parent portal to view progress and other information. If you select no here, this contact will not see the student on the parent portal.

I consent that IBEUK can process this form and submit directly to Southend Mosque Madrasa. Your data will not be stored nor used by us.