The Atlanta Dar-Ul-Uloom - Application For Admission (Page 2 of 4) in pdf

The Atlanta Darul-Uloom

Street, NW, Atlanta GA. 30318. Tel: 678-886-2966 – 678-705-3241

Head Office: 442 14

APPLICATION FOR ADMISSION

Date: _________________

Ref No.______________

PERSONAL INFORMATION:

Student information:

Student’s Surname ______________________First Name: ____________________________Middle Name____________________

Street Address: __________________________________________ City: ____________________State: _________ Zip: ________

Home Telephone: (______)___________

Boarding (overnight stay) required:

Yes

Date of Birth: ___/___/____ Place of Birth: ______________________________________________________ Sex:

Male

Female

Social Security No: _______-______-_____________ US Citizen

Yes

No If NO, Green Card Holder

Yes

If not U.S. Citizen or Green Card Holder, does the Student Visa: Yes

No. If Yes provide the detail below:

Visa Expiry date: ___/___/______

Passport Number: _______________

Health Insurance Name: ________________________________________________________ Number: _______________________

Doctor’s Name: _______________________________________________________________Phone No: (____)________________

Does the student suffer from any serious or long-term illness (e.g. Epilepsy, Bronchitis, and frequent Headaches)? ______________

. ___________________________________________________________________________________________________________

Does the student suffer from any allergies? : ________________________________________________________________________

Yes If ‘Yes’ please give details and court judgment: _________

Has the student ever been involved with the police?

_______________________________________________________________________________________________________

Parent/Guardian information:

Parent’s or Guardian’s full Name: _____________________________________________________________

Occupation: ___________________________ Work Telephone: (____)______________

Place of Employment: Name: ____________________________________________________________

Address: ______________________________________________________________________________

If Parents divorced or separated:

who is the Custodial Parent?

Mother

Father Please provide address for both below:

Address of Father: ____________________________________________________________________________________

Address of Mother: ____________________________________________________________________________________

The Atlanta Dar-Ul-Uloom - Application For Admission Page 2