Returning Student Registration Form

Please fill out this form only if you have attended Madinah Academy within the past three years. If you are a returning student, but it has been more than three years since you attended the Academy, you are considered a new student and should fill out this form.

Attended Madinah Previously?

Yes

Has your contact information changed since last year?

Yes

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.

Madinah Academy of Madison

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