MDQ Academy Revised March 2016 Page 1 of 4

1725 Brentwood Road, Brentwood, NY 11717 Phone: 631-665-5036 | Fax: 631-521-7718 administration@mdqacademy.org www.mdqacademy.org

Registration Form

2017-2018

Section A - Student

Last Name

First and middle names

2. Sex M / F

Date of Birth

Place of Birth (city and state/country) Home School District

Home address

City

State Zip code

Last School Attended

Last Date of Attendance

School Address

School phone number

Ethnic group

American Indian or Alaskan Native Hispanic or Latino White

Asian or Native Hawaiian or Other Pacific Islander Black or African American Multiracial

Section B - Health & Well Being

Name of Doctor/Clinic Phone

Allergies

Medical/behavioral or other problems Special Considerations

Medications Reasons

Section C - Siblings

Please list your other children who are enrolled in MDQ Academy School:

Name Grade

I am aware of MDQ Academy policies, terms, and conditions. I understand that by registering and maintaining enrollment, parents and students agree to abide by all school policies, terms, and conditions. Signature

Date

For Office Use Only

Enrollment date: ____________________

Grade to be enrolled: ________________

Received by: _______________________

Principal’s Signature: ________________

Interview Test File complete

Application fee Registration fee

Photo

http://compose.mail.yahoo.com/?To=info%40almadinah-school.com

MDQ Academy Revised March 2016 Page 2 of 4

Section D - Family Information

Student(s) living with (please check one): Natural parent(s) Foster parent(s) Other relative

1. Mother or Primary Guardian

Last name

First and Middle Names

Relationship to Student

Address (if different from student’s)

Home Phone Number

Work Phone Number Cell Phone Number

Alternate Phone Number Email Occupation

2. Father or Second Guardian

Last name

First and middle names

Relationship to student

Address (if different from above)

Home phone number

Work phone number Cell phone number

Alternate Phone Number Email Occupation

Student name(s) and grade(s)

Section E – Emergency Contacts

If your child(ren) becomes ill while in MDQ Academy, but does not require emergency treatment, you and person(s) listed by you below will be contacted at the registered phone numbers. If your child(ren) require/s emergency medical care, you will be called immediately. If we cannot reach you, the child(ren)’s family doctor will be called or the child(ren) will be taken to the nearest emergency room for treatment which is Southside Hospital, 301 E. Main Street, Bay Shore, NY 11706. In the event that you are not available, or unable to pick up your child(ren) from MDQ Academy at the time of dismissal, the person(s) listed below is/ are authorized to pick up your child(ren) in your place.

Two or more persons to be contacted if you cannot be reached (do not include parents/guardians listed in Section D):

Name Relationship to child Phone(s)

I hereby give my consent to the staff at MDQ Academy to authorize emergency medical, surgical and/or dental treatment for my child if I cannot be reached. I request that the MDQ Academy staff require proof of identification of any substitute who shall pick up my child in my place. In consideration of the services provided to my child by MDQ Academy, I hereby agree to indemnify and hold harmless MDQ Academy, its directors, agents, employees or volunteers from any and all losses, liabilities, claims, damages, costs and expenses which may arise as a consequence or result of the release of my child to any of the aforementioned substitutes.

Signature

Date

MDQ Academy Revised March 2016 Page 3 of 4

Student name(s) and grade(s)

Required Documents for Student Enrollment The following documents are required at the time of registration.

Birth certificate: A birth certificate is required for children enrolling in MDQ Academy School for the first time (translation required if birth certificate is in a foreign language).

Proof of required immunizations: State Education Law requires that all new students entering school or already in preschool or grades KG, 2, 4, 7, 10, have a physical/medical examination including immunization and BMI. Optional Dental Certificates may also be requested.

Proof of medical/physical examination: see Immunizations above. Proof of address: Recent utility bill with parent’s name, driver’s license, notarized letter or landlord/tenant form. Most recent report card/transcript: Kindergarten and up. Recent passport-size photo: All girls must submit pictures with Hijab.

Student Enrollment Policy

A-Head Start: For potty-trained children who are 3 years (pending with conditions) of age. Students must also pass an interview and/or placement test.

Pre-K: For children who will be 4 years old on or before Dec.1st. Younger age transfers may not be accepted. Students must also pass an interview and/or placement test.

Kindergarten: For children who will be 5 years old on or before Dec. 1st. Students must also pass an interview and/or placement test.

1st grade: For children who will be 6 years old on or before Dec. 1st or who have successfully completed Kindergarten (proof required upon enrollment). Students must also pass a placement test and an interview.

2nd – 12th grade: For students who have successfully completed the previous grade. Report card is required upon enrollment. Student must also pass a placement test, iReady diagnostic and an interview.

Uniform Policy

Our school uniform creates a sense of unity and order in the school. Students are expected to wear the proper uniform at all times. Students who are not dressed properly will be sent home. Please make sure your child has an extra uniform.

Girls ● Pre-K through 3rd grade: Navy blue jumper, black shoes with rubber soles, no laces, no heels. ● 4th grade and up: Navy blue jilbab, white hijab/khimar, black shoes with rubber soles, no laces, no heels. Boys ● Navy blue dress pants, light blue shirt, black shoes/sneakers with rubber soles, no laces. ● “V” neck Blue sweater or Blue cardigan (sweater jacket).

● Boys are allowed to wear white jalabiyas and kufis on Fridays. Tuition

Please note that the registration fees, tuition for the month of September, and the additional fees are due at registration time. All are non-refundable/non-transferable. Registration will not be accepted without full payment of these fees. The above does not include any other obligatory fees (such as graduation, fund raising activities, field trips, books, instructional materials, lab fees, etc...).

Application fee: (first time only) $25.00 due upon application submission and before test/interview.

Registration fee: Yearly $300.00 due in full upon registration.

Supply fee: Yearly for lower grades (A-Head Start, Pre-K, KG) $50 due upon registration.

Tuition: 1 child: $4,850 yearly 4 children: $14,500 yearly 2 children: $8,550 yearly 5 children: $16,450 yearly 3 children: $11,800 yearly 6 children: $16,450 yearly

Activity fees: Parents will be notified of field trips, various activities and applicable fees throughout school year.

Graduation fee: Applicable to graduating classes only – Pre-K, 5th, 8th, 12th : $75.00.

Yearly financial aid: Please inquire at the office for deadlines to apply for aid (a major part comes from Masjid Darul Qur’an’s Zakat fund).

Late fee: Monthly tuition is due on the 1st of every month. Quarterly tuition is due on September 1st, November 1st, February 1st, and April 1st. A Late fee of $25.00 will be posted on your account in the event of an incomplete/missing payments after the 10th of the month regardless of the day of the week, holidays, child’s absence or suspension.

MDQ Academy Revised March 2016 Page 4 of 4

Agreement 1. MDQ Academy reserves the right to deny registration or to place conditions upon enrollment. Parents whose child(ren) is/are on a waiting list are responsible for non-refundable application fee ($25). If the child is accepted, the parents have two days to come and pay registration and first month’s tuition. Failure to do so will result in the child losing the seat. Registration fee will not be refunded if parent changes his/her mind. Waiting lists are on a first come, first served basis – seats are limited. After-school, weekend school and summer programs require separate agreements. 2. MDQ Academy reserves the right to expel a student at any time (due to safety, behavioral, academic reasons or non-payment of dues). MDQ Academy reserves the right to request parents to enroll a special needs student at another facility, in order for the student to receive professional special needs services that MDQ Academy cannot provide. MDQ Academy reserves the right for academic/behavioral or other screening of any student. If further evaluation is recommended, the school district and/or parents will be notified. Un-Islamic behavior by parents on school premises will not be tolerated and may affect the enrollment of their child/ren (expulsion). Parents and students must abide by all school rules and regulations (e.g. uniform, I.D., etc.). The school reserves the right to fail any student who does not meet school standards. 3. Tuition is not refundable or transferable for any reason such as suspensions, expulsions, or school closings. In order to re-register, all previous accounts must be paid in full. School records and all official letters will be held until all accounts are paid in full. Full tuition is required even if the child is enrolled late. Parents who withdraw their child/ren anytime during the school year are responsible for the full tuition. Upon withdrawal from the school, all payments must be paid in cash or money order (no checks). Returned/bounced checks due to “insufficient funds” will incur a fee of a minimum of $20 per check. Parents are responsible for paying for any lost/stolen textbooks. Parents are entitled to all workbooks. Parents are expected to raise at least $1000 in donations each year. 4. Students left by parents/guardians in the school building before/after school hours will not be the responsibility of the school. Students who are picked up after dismissal time will be charged a late pick-up fee. 5. MDQ Academy reserves the right to photograph or otherwise record any child participating in a MDQ Academy program or event and to use, reuse, and publish any such photograph or recording in any publication, including but not limited to yearbook, flyers, brochures, ads, and social media without inspection or approval from parents/guardians or any compensation or consideration. MDQ Academy cannot be held accountable for any liability resulting from the publication, distribution or use or reuse of same. Parents may file written “do not photograph/do not record” statement with main office in the form of a letter. 6. MDQ Academy reserves the right to obtain any child’s existing educational records as well as latest immunization and physical forms from all involved schools, school districts, testing facilities and doctors. 7. MDQ Academy cannot be held accountable for any liability resulting from student participation in field trips, except in case of its sole and gross negligence, for damage because of bodily injury, including death at any time resulting therefrom, sustained by any child or by any person or persons, or on account of damage to property arising out of such participation. A permission slip must be signed by parents for every trip separately. 8. MDQ Academy cannot be held accountable for any liability resulting from student participation in any physical activities provided by MDQ Academy including but not limited to gym, except in case of its sole and gross negligence, for damage because of bodily injury, including death at any time resulting therefrom, sustained by any child or by any person or persons, or on account of damage to property arising out of such participation. Parents may file written “non-participation” statement from student’s doctor detailing temporary or permanent physical limitations due to a medical condition with school nurse. 9. By registering and maintaining enrollment, parents and students agree to abide by all school policies, terms, and conditions.

Name of Mother/Guardian

Name of Father/Guardian

Signature

Date Signature Date

MDQ ACADEMY 1725 Brentwood Road, Building 2

Brentwood, NY 11717 Phone: (631) 665-5036

Fax: (631) 521-7718

Emergency Medical Authorization Form 2017-2018 Please fill out this form and return it to your child’s school.

Student Name: _________________________________Grade:______ Date of Birth: _________

Student’s Address: ______________________________________________________________

City: _______________________________________ State: _________ Zip: ____________

Purpose — To enable parents and guardians to authorize the provision of emergency treatment for

children who become ill or injured while under school authority, when parents or guardians cannot be

reached.

Residential Parent or Guardian Mother’s Name: Daytime Phone:

Residential Parent or Guardian Father’s Name: Daytime Phone:

Name of Relative or Emergency Contact: Relationship Daytime Phone:

PART I or II MUST BE COMPLETED

PART I: TO GRANT CONSENT

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for

(1) the administration of any treatment deemed necessary by a licensed physician or dentist; and (2) the

transfer of my child to any hospital reasonably accessible. This authorization does not cover major

surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the

necessity for such surgery, are obtained prior to the performance of such surgery.

Facts concerning my child’s medical history, including allergies, medications being taken, and

any physical impairments to which a physician should be alerted:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Parent/Guardian Name: Parent/Guardian Signature: Date:

MDQ ACADEMY 1725 Brentwood Road, Building 2

Brentwood, NY 11717 Phone: (631) 665-5036

Fax: (631) 521-7718

PART II: REFUSAL TO GRANT CONSENT

I do NOT give my consent for emergency medical treatment of my child. In the event of illness

or injury requiring emergency treatment, I wish the school to take the following action:

Parent/Guardian Name: Parent/Guardian Signature: Date:

MDQ ACADEMY 1725 Brentwood Road, Building 2

Brentwood, NY 11717 Phone: (631) 665-5036 | Fax: (631) 521-7718

Release of Records Request

Name of Student Date

Date of Birth Grade Level

To:

School Name

School Address

School Phone/Fax

We kindly request for you to forward any and all academic and behavioral records pertaining to the above

named student, including Final Report Cards/Transcripts, Medical Records, Standardized Test Scores,

Attendance, Disciplinary Reports, IEP’s, etc.

Please forward all records to:

MDQ ACADEMY 1725 Brentwood Road, Building 2

Brentwood, NY 11717

I hereby give permission for MDQ Academy to communicate, receive and exchange relevant information pertinent to the above student with the above listed school.

Parent/Guardian Name Date

Parent/Guardian Signature Phone Number

TYPE OF EXAM: NAE Current NAE Prior Year(s)

Comments

REVIEWER:

Date Reviewed:

DOHMHONLY

PROVIDER I.D.

__ __ / ___ ___ / ___ ___

I.D. NUMBER

Health Care Provider Signature Date__ __ / ___ ___ / ___ ___

Health Care Provider Name and Degree (print) Provider License No. and State

Facility Name National Provider Identifier (NPI)

Address City State Zip

Telephone ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Fax ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Hep B __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Rotavirus __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

DTP/DTaP/DT __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Hib __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

PCV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Polio __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

RECOMMENDATIONS � Full physical activity � Full diet

� Restrictions (specify) ___________________________________________________________________________

Follow-up Needed � No � Yes, for _________________________ Appt. date: __ __ / ___ ___ / ___ ___

Referral(s): � None � Early Intervention � Special Education � Dental � Vision

� Other ________________________________________________________________________

ASSESSMENT � Well Child (V20.2) � Diagnoses/Problems (list) ICD-9 Code

_____________________________________________________________ __ __ __ __ __

_____________________________________________________________ __ __ __ __ __

_____________________________________________________________ __ __ __ __ __

Health insurance � Yes(including Medicaid)? � No

Does the child/adolescent have a past or present medical history of the following?� Asthma (check severity and attach MAF/Asthma Action Plan): � Intermittent � Mild Persistent � Moderate Persistent � Severe Persistent

If persistent, check all current medication(s): � Inhaled corticosteriod � Other controller � Quick relief med � Oral steroid � None

� Attention Deficit Hyperactivity Disorder � Orthopedic injury/disability� Chronic or recurrent otitis media � Seizure disorder� Congenital or acquired heart disorder � Speech, hearing, or visual impairment� Developmental/learning problem � Tuberculosis (latent infection or disease)� Diabetes (attach MAF) � Other (specify) ___________________

Explain all checked items above or on addendum

Birth history (age 0-6 yrs)

� Uncomplicated � Premature: ________ weeks gestation

� Complicated by _______________________________

Allergies � None � Epi pen prescribed

� Drugs (list)

� Foods (list)

� Other (list)

STUDENT ID NUMBEROSIS

CHILD & ADOLESCENT HEALTH EXAMINATION FORMNYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

Please Print Clearly

Press Hard

Child’s Last Name First Name Middle Name

Child’s Address

City/Borough State Zip Code

� Parent/Guardian Last Name First Name� Foster Parent

School/Center/Camp Name

Sex � Female � Male

Hispanic/Latino?� Yes � No

Race (Check ALL that apply) � American Indian � Asian � Black � White� Native Hawaiian/Pacific Islander � Other ____________________________

PHYSICAL EXAMINATION

Height ____________________ cm ( ___ ___ %ile)

Weight ____________________ kg ( ___ ___ %ile)

BMI ____________________ kg/m2 ( ___ ___ %ile)

Head Circumference (age ≤2 yrs) ______________ cm ( ___ ___ %ile)

Blood Pressure (age ≥3 yrs) _________ / __________

DEVELOPMENTAL (age 0-6 yrs) � Within normal limits

If delay suspected, specify below

� Cognitive (e.g., play skills) ____________________________

� Communication/Language _________________________

� Social/Emotional __________________________________

� Adaptive/Self-Help ________________________________

� Motor ___________________________________________

SCREENING TESTS Date Done Results

Blood Lead Level (BLL)__ __ / ___ ___ / ___ ___ _________ µg/dL

(required at age 1 yr and 2 yrsand for those at risk) __ __ / ___ ___ / ___ ___ _________ µg/dL

Lead Risk Assessment � At risk (do BLL)(annually, age 6 mo-6 yrs)

__ __ / ___ ___ / ___ ___ � Not at risk

Hearing � Pure tone audiometry � Normal� OAE __ __ / ___ ___ / ___ ___ � Abnormal

—— Head Start Only ——

Hemoglobin or __________ g/dLHematocrit (age 9–12 mo)

__ __ / ___ ___ / ___ ___ __________ %

Date Done Results

Tuberculosis Only required for students entering intermediate/middle/junior or high schoolwho have not previously attended any NYC public or private school

PPD/Mantoux placed __ __ / ___ ___ / ___ ___ Induration ______mm

PPD/Mantoux read __ __ / ___ ___ / ___ ___ � Neg � Pos

Interferon Test __ __ / ___ ___ / ___ ___ � Neg � Pos

Chest x-ray � Nl � Not(if PPD or Interferon positive)

__ __ / ___ ___ / ___ ___� Abnl Indicated

Vision

__ __ / ___ ___ / ___ ___

Acuity Right ___ / ___(required for new school entrants Left ___ / ___and children age 4–7 yrs) � with glasses Strabismus � No � Yes

General Appearance:

Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl

� � HEENT � � Lymph nodes � � Abdomen � � Skin � � Psychosocial Development� � Dental � � Lungs � � Genitourinary � � Neurological � � Language� � Neck � � Cardiovascular � � Extremities � � Back/spine � � Behavioral

Date of Birth (Month/Day/Year )__ __ / ___ ___ / ___ ___ ___ ___

Phone Numbers

Home _____________________

Cell ______________________

Work ______________________

TO BE COMPLETED BY PARENT OR GUARDIAN

TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)

CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian

Medications (attach MAF if in-school medication needed)� None � Yes (list below)

Dietary Restrictions� None � Yes (list below)

Influenza __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

MMR __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Varicella __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Td __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Tdap __ __ / ___ ___ / ___ ___ Hep A __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Meningococcal __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

HPV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Other, specify: ____________ __ __ / ___ ___ / ___ ___ ; _______________ __ __ / ___ ___ / ___ ___

IMMUNIZATIONS – DATES CIR Number of Child

Describe abnormalities:

District __ __Number __ __ __