MDQ Academy Revised March 2018 Page 1 of 4

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

Registration

Form 2018-2019

Section A - Student

Last Name First and middle names 2. SexM / 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 2018Page 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/orplacement 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 ● KG-12: School uniform (assigned to each grade level), black shoes with rubber soles, no laces, no heels.● Gym Uniform: PE uniforms with athletic shoes. More information available in the Main office.

Boys ● Navy blue dress pants, light blue shirt with school logo patch (available in the Main office), black shoes/sneakers withrubber 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: (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

Technology fees: All grades yearly $40 due upon registration. 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 havetwo 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 Academyreserves the right for academic/behavioral or other screening of any student. If further evaluation is recommended, theschool district and/or parents will be notified. Un-Islamic behavior by parents on school premises will not be tolerated andmay affect the enrollment of their child/ren (expulsion). Parents and students must abide by all school rules andregulations (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 tore-register, all previous accounts must be paid in full. School records and all official letters will be held until all accounts arepaid in full. Full tuition is required even if the child is enrolled late. Parents who withdraw their child/ren anytime during theschool year are responsible for the full tuition. Upon withdrawal from the school, all payments must be paid in cash ormoney order (no checks). Returned/bounced checks due to “insufficient funds” will incur a fee of a minimum of $20 percheck. Parents are responsible for paying for any lost/stolen textbooks. Parents are entitled to all workbooks. Parents areexpected 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 theschool. 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 programor event and to use, reuse, and publish any such photograph or recording in any publication, including but not limited toyearbook, flyers, brochures, ads, and social media without inspection or approval from parents/guardians or anycompensation 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 mainoffice 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 andphysical 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 incase 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. Apermission 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 activitiesprovided by MDQ Academy including but not limited to gym, except in case of its sole and gross negligence, for damagebecause of bodily injury, including death at any time resulting therefrom, sustained by any child or by any person orpersons, 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 withschool nurse.9. By registering and maintaining enrollment, parents and students agree to abide by all school policies, terms, andconditions.

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 2018-2019 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

Rev. 5/4/2018 Page 1 of 2

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or

Committee on Pre-School Special education (CPSE).

STUDENT INFORMATION

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐ Medication ☐ Environmental

Asthma ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐ Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________

Diabetes ☐ No ☐ Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached

☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HbA1c results: ____________ Date Drawn: _____________Risk Factors for Diabetes or Pre-Diabetes:

Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.

Hyperlipidemia: ☐ No ☐ Yes Hypertension: ☐ No ☐ Yes

PHYSICAL EXAMINATION/ASSESSMENT

Height: Weight: BP: Pulse: Respirations:

TESTS Positive Negative Date Other Pertinent Medical Concerns

PPD/ PRN ☐ ☐ One Functioning: ☐ Eye ☐ Kidney ☐ Testicle

Sickle Cell Screen/PRN ☐ ☐ ☐ Concussion – Last Occurrence: __________________________

Lead Level Required Grades Pre- K & K Date ☐ Mental Health: ________________________________

☐ Other: ☐ Test Done ☐ Lead Elevated > 10 µg/dL

☐ System Review and Exam Entirely Normal

Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities

☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech

☐ Dental ☐ Cardiovascular ☐ Back/Spine ☐ Skin ☐ Social Emotional

☐ Neck ☐ Lungs ☐ Genitourinary ☐ Neurological ☐ Musculoskeletal

☐ Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

Rev. 5/4/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

Pure Tone Screening ☐ Yes ☐ No

Scoliosis Required for boys grade 9 Negative Positive Referral

And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No

Deviation Degree: Trunk Rotation Angle:

Recommendations:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ Full Activity without restrictions including Physical Education and Athletics.

☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications

☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling

☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, Skiing, swimming and diving, tennis, and track & field

☐ Other Restrictions:

☐ Developmental Stage for Athletic Placement Process ONLY

Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports

Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V

☐ Accommodations: Use additional space below to explain

☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids

☐ Insulin Pump/Insulin Sensor* ☐ Medical/Prosthetic Device* ☐ Pacemaker/Defibrillator*

☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other: *Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.

Explain: _____________________________________________________________________________

MEDICATIONS

☐ Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.