Student Registration

This form may be completed by:

new students, who have never been enrolled in an ILIA class
existing students who need to update their information with ILIA.

Student Information

First Name

Middle Name

Last Name

Date of Birth

Gender

MaleFemale

Citizenship Status

Other Citizenship

Hobbies

Hold Ctrl when clicking to select multiple options.

Other Hobbies

List 5 strengths:

List 3 weaknesses:

Why are you interested in applying to ILIA?

Briefly share your short-term goals and longer-term life mission.

Which of the following are you interested in doing at ILIA?

Hold Ctrl when clicking to select multiple options.

Variants

Hold Ctrl when clicking to select multiple options.

Other Variants

Backend Processing

Option

Can be "Paid" or "Free". Defaults to a paid form if blank.

Disable payment if free

Student Contact Information

Country

Student Street Address

Student City

Student State

Student ZIP Code

Student Home Phone

Student Mobile Phone

Student Email Address

Confirm Student Email Address

Emails do not match.

Matching student emails

Education

If you are currently in school, enter information about your current school. Otherwise, enter information about the last educational institution you attended.

Are you being home schooled?

Yes

Educational Phase

School Name

GPA

Any special education needs or disabilities requirements?

Any special counseling services needed?

Parent/Guardian Information

Guardian 1 Relationship

Guardian 2 Relationship

Guardian 1 Information

Guardian 1 First Name

Guardian 1 Last Name

Guardian 1 Mobile Phone

Guardian 1 Email Address

Guardian 2 Information

Guardian 2 First Name

Guardian 2 Last Name

Guardian 2 Mobile Phone

Guardian 2 Email Address

Medical History

Any allergies?

Yes

Currently on medication?

Yes

Ever hospitalized?

Yes

Any injuries?

Yes

Please select any allergies you have.

Allergies

Hold Ctrl when clicking to select multiple options.

Other Allergies

Current Medications

Injuries

Hospitalizations

References

Reference 1

Can be a school teacher, coach or mentor.

Reference 1 First Name

Reference 1 Last Name

Reference 1 Mobile Number

Reference 1 Email

Reference 1 Affiliation (Organization)

Reference 2

Can be an imam, community leader, or school administrator.

Reference 2 First Name

Reference 2 Last Name

Reference 2 Mobile Number

Reference 2 Email

Reference 2 Affiliation (Organization)

Payment

There is a one-time, nonrefundable $50.00 fee for student sign-ups.

Discount Code

If provided with one, enter your discount code here

Do you require financial aid (zakat)?

YesNo

Financial Aid Instructions

Please complete a zakat application. Applications available online here.

Please reach out to us at ss@islamicleadership.org for any questions regarding financial aid.

Please check the box below once an application has been submitted.

I have submitted a zakat application.

Payment Information

Price

$

Cardholder's Full Name

Card Number

CVV

Expiration Month

Expiration Year

Billing Email Address

African	Central/SE/East Asian
Caucasian	Hispanic/Latino
Middle Eastern	India/Pakistan/Bangladesh
Native American	Mixed

Father	Mother
Grandfather	Grandmother
Uncle/Aunt	Siblings
Cousins	Other