This registration form has 4 pages. You must complete all sections by clicking Next at the end of each page. Click Submit on the last page to send your application.
Agreement & Signature
Review Your Entry
Applying For (select 1 or more) *
If you are enrolling more than 1 students, please complete this form for each student.
Please complete this section entirely.
Home Address *
Release of Liability and Assumption of Risk
Please read the following carefully before signing and submitting this form.
I understand this is a legal representation of my signature.
Please review your entry below. Click submit button to finish.
Applying For (select 1 or more)
Date of Birth
Does your child have any previous experience at another Islamic School? If so, what is the name of that school and how long did they attend ?
What is your child current grade level in school (K through 12)?
1st Parent Name
1st Parent/Guardian Role
1st Parent E-Mail
1st Parent Cell Phone
2nd Parent Name
2nd Parent/Guardian Role
2nd Parent Cell Phone
Emergency Contact Person (if parents unavailable)
Emergency Contact Phone #
Please describe any food alergies we should be aware of, if any.
Please describe any medical or health conditions we should be aware of relating to your child, if any.
Does your child have any special needs or disability needs ? If yes, explain. If not say No
I, on behalf of my minor child/children hereby waive in advance any and all actions or claims of injury or property damage which may occur as a result of my child/children participating in any activity or activities sponsored by Ansaar Academy. I hereby release and hold harmless the Inland Empire Community Wakf, the Islamic Center of Inland Empire, Ansaar Academy and the officials, employees, volunteers, and agents of these organizations.
I permit the taking of photographs of themselves and or minor children by the Islamic Center of Inland Empire and Ansaar Academy during the activities.
I permit off-site field activities when notified in advance.
I am aware that Parents are responsible for reading the school booklet.