Darul-Uloom Al-Madania Inc.

182 Sobieski Street, Buffalo, NY 14212, U.S.A.

Tel: (716) 892-2606, (716) 895-3318; Fax: (716) 892-6621 www.madania.org

DATE:

_______________

STUDENT INFORMATION
Full Name __________________________________________________________________________________
(First Name)

(Middle Name)

(Last Name)

Address ____________________________________________________________________________________
(Street)

(City)

Tel. Number: HOME _____________________

(State)

WORK

(Zip Code)

(Country)

____________________ CELL __________________

Citizenship ___________ Status in US _________ Length of stay in US____________ DOB ______________

Place of Birth _____________________________ Gender: M [ ] F [ ] Social Security # ________________
(City)

(Country)

EDUCATION
Present Religious Education:
Name of Institute Attended ____________________________________________________________________
Address ____________________________________________________________________________________
( Street)

(City)

(State)

(Zip Code)

(Country)

Tel. Number: __________________ Names of languages you studied/know:_____________________________

Attended Date From: ____________ To: ______________ Reason for Leaving ___________________________
Number of times the Nazira has been repeated __________

How much Quran memorized _________________

Present Secular Education:

Name of School/College Last Attended ___________________________________________________________
Address ____________________________________________________________________________________
(Street)

(City)

(State)

(Zip Code)

(Country)

Tel. Number: _________________ Dates: From _____________ To____________ Grade Attained _________
ADMISSION APPLIED FOR:
CHECK ONE ONLY:

Hifz Class [ ]

(Boys Only)

Alim/Alimah Class [ ]

PARENT/GUARDIANS INFORMATION
Full Name __________________________________________________________________________________
Address ____________________________________________________________________________________
(Street)

(City)

Tel. Number: HOME ___________________

Citizenship ____________

WORK

(State)

(Zip Code)

(Country)

___________________ CELL ______________________

Occupation _______________ Email ____________________________________

Place of Birth _____________________________________

(City)

Social Security # __________________________

(Country)

EMERGENCY CONTACT
Name ______________________________________________

Tel. Number __________________________

Address ____________________________________________________________________________________
(Street)

Relation to Student: ____________________

_____________________________
Signature of Student

(City)

(State)

(Zip Code)

(Country)

Email ______________________________________________

_____________________________
Signature of Parent/Guardian