Call Us: 607 533 0357
Email: contactus@alhudaislamiccenter.org

607 533 0357
contactus@alhudaislamiccenter.org

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Student Registration Form Header

Student Registration Form

School Year *

Instruction

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Student Information

Student Status *

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Male / Female *

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Student First Name *

Student Last Name *

Ethnicity / Race

Date of Birth (MM/DD/YYYY) *

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School Grade

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Parent Guardian Information Form

Parent / Guardian Information

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Phone *

Email *

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Parent Address Information

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Parent City

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Emergency Contact Information

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Emergency Contact #1

E Contact #1 First Name

E Contact #1 Last Name

E Contact #1 Phone

E Contact #1 Relationship to the Child

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Emergency Contact #2

E Contact #2 First Name

E Contact #2 Last Name

E Contact #2 Phone

E Contact #2 Relationship to the Child

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Pick Up Authorization Form

Authorization Form Instructions

Who do you authorize to pick up your Child in case you are not able to do it?

Please list Name/s below
Don't forget to include the relationship to the child.

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Auth 1 First/Last Name

Auth 1 Relationship to Student

Auth 2 First/Last Name

Auth 2 Relationship to Student

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Full Name *

Signature *

Today's Date *

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Completed Instruction

Once completed
Please press the SUBMIT Button below.....

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CIS Student Registration Input Form

Student Registration Form

Student Information

Parent / Guardian Information

Parent Address (If different from above)....

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

Pick Up Authorization Form

Who do you authorize to pick up your Child in case you are not able to do it?

Please list Name/s belowDon't forget to include the relationship to the child.

Once completedPlease press the SUBMIT Button below.....

Please list Name/s below
Don't forget to include the relationship to the child.

Once completed
Please press the SUBMIT Button below.....