Existing Student Data Enrolment - Islamic Academy of Coventry

Existing Student Electronic Data Enrolment Form

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Student Details

Gender

Male
Female

Full Name

First

Last

Date of Birth

Student Age

Students age in years

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Mobile/Primary Phone

Mobile or primary contact number

Home Phone

Home landline number if you have one, or alternate contact number

Nationality

Please select your nationality

Country of Origin

Please select your country of origin (where you born, if different from your nationality)

Course/Education

Please check the minimum age entry requirements for courses on the classes page of the Academy website before applying for any course

Emergency Contact

Full Name of Emergency Contact

First

Last

Is the emergency contact's address different from above?

Emergency Contact Mobile/Primary Phone

Mobile or primary contact number

Emergency Contact Home Phone

Home landline number if you have one, or alternate contact number

Emergency Contact Work Phone

Enter a work telephone number if you have one and may need to be contacted on it

Medical

Name of Doctor

Please enter your Dr’s full name

Doctor's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Doctor's Phone

Applicant's Medical Number

Please provide the applicants NHS number if known

Does the applicant have any long term medical illnesses?

Does the applicant suffer from any allergies?

Does the applicant have any special educational needs?

Medical Consent

I, the parent of the above named child
I, the guardian of the above named child
I, the student

hereby give permission for the Islamic Academy of Coventry to give the immediate necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my/my son/daughter’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent. Note. Please note that a young person can give their own consent for medical treatment if they are over 16.

By selecting a choice you hear by give consent

Rules and Regulations

All new applicants will have to pass the admission test.
Disclosure of all previous character and conduct is necessary.
It is necessary to attend all lessons.
All Islamic Laws and regulations will have to be followed in all aspects of life particularly prayers, dress, social affairs, etc.
To insult the trustees, teachers or staff of the Academy (verbally or physically) will be judged as inexcusable and any student found guilty of such behaviour will be liable for dismissal.
The Academy reserves the right to expel any student when it deems necessary. Anyone expelled will have no legal remedy against the Academy.
Any false information given will be liable for immediate dismissal.
The student/parent/guardian will be held fully responsible for the cost of any damage to the property of Islamic Academy of Coventry.
All the above rules and regulations will have to be adhered to fully.

Declaration

The information I have given on the form is true and accurate to the best of my knowledge. I understand that my application will be disqualified if I have knowingly given false information.
I have read or had explained to me and understand all the questions and rules and regulations on this form.
I have read and accept to follow all the rules and regulations of Islamic Academy of Coventry.

By clicking submit you agree to the above terms and rules of the Academy