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 child: Autofill: Father Mother Brother Sister

Type:

*Your email:

*Confirm email:

Telephone:

Mobile:

Address: Postcode:

Students

Child #1:

Surname:

D.O.B:

Gender:

Email:

Enroll:

Mondays to Wednesdays 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.:

Mobile:

Alt. Mob.:

Relation:

Type:

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