New Student Registration Application

If you intend to send your child to Madinah Academy, please fill out this form. Please submit one form per child. Once your application has been reviewed, you will be contacted by an admissions counselor.

Student Name

First Name

Last Name

Last Grade Completed

Grade Level

Last School attended

Date of Birth

YYYY

Social Security Number

Place of Birth

Age by Dec 1st 2020

Sex

Male

Female

Address

City

State

Zip Code

Must be 5 digits

Parent/Guardian

Must have at least one Guardian

First Name

Last Name

Second Parent/Guardian

(optional)

First Name

Last Name

Phone

(###)

###

####

Must have at least one email

Second Email

(optional)

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

Contact Relation

Contact's relation to the student. Ex, aunt, uncle, friend, etc.

Are you applying for the Choice Program?

Yes

Madinah Academy of Madison

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