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TRANSCRIPT
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MDQ Academy Revised March 2016 Page 1 of 4
1725 Brentwood Road, Brentwood, NY 11717 Phone: 631-665-5036 | Fax: 631-521-7718 [email protected] 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
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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
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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.
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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
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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:
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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:
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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
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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 __ __ __