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Registration

The Islamic Education School

Annual Student Registration Form

Student Information

Student Name(Required)

First Middle Last

Grade Level(Required)

Birth Date(Required)

MM slash DD slash YYYY

Gender (Choose one)(Required)

Languages spoken at home(Required)

Student's Email Address (Grades 1-9)

Student's Mobile Phone (Grades 1-9)

Siblings [Brothers and Sisters] (Skip if not applicable)

Name

First Last Age

Name

First Last Age

Name

First Last Age

Name

First Last Age

PARENT INFORMATION

Note: TIES sends school information and announcements via text/voice/email. Please complete all information accurately

Guardian 1 Name(Required)

First Middle Last

Relationship(Required)

Guardian 1 Email(Required)

Guardian 1 Home Phone

Guardian 1 Work Phone

Guardian 1 Mobile Phone(Required)

Guardian 2 Name(Required)

First Middle Last

Relationship(Required)

Guardian 2 Email(Required)

Authorized For Student Information Release(Required)

Yes

No

Guardian 2 Home Phone

Guardian 2 Work Phone

Guardian 2 Mobile Phone(Required)

Authorized For Student Information Release(Required)

Yes

No

Parents are:(Required)

Married

Divorced

NOTE: Step-Parent Information is requested in a separate section

STUDENT/PARENT PRIMARY ADDRESS

Address(Required)

Street Address Address Line 2 City State ZIP Code

SCHOOL HISTORY

Last School Attended(Required)

Address

Street Address Address Line 2 City State ZIP Code

EMERGENCY CONTACT

Emergency Contact 1(Required)

First Last

Relationship to Student(Required)

Phone(Required)

Emergency Contact 2

First Last

Relationship to Student

Phone

Emergency Contact 3

First Last

Relationship to Student

Phone

Health

Physician's Name(Required)

First Last

Physician's Phone(Required)

Physician's Address(Required)

Street Address Address Line 2 City State ZIP Code

Medical conditions (Put N/A if not applicable)(Required)

Allergies (Put N/A if not applicable)(Required)

Medications and dosage (Put N/A if not applicable)(Required)

ADDITIONAL STUDENT INFORMATION

Does student have an IEP?(Required)

Yes

No

Does student a hearing impairment?(Required)

Yes

No

Does student a visual impairment?(Required)

Yes

No

Does student need learning modifications?(Required)

Yes

No

STEP-PARENT INFORMATION (Skip if not applicable)

Step-father's Name

First Last

Step-father's Email Address

Authorized To Receive School/Student Information

Step-father's Phone Number

Step-mother’s Name

First Last

Step-mother’s Email Address

Authorized To Receive School/Student Information

Step-mother’s Phone Number

STUDENT / PARENT SECONDARY ADDRESS (Skip if not applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Media Permission

TIES Revere routinely posts on our websites and other publications pictures and videos of student activities connected with the school.(Required)

TIES may include my child in such postings.

TIES may not include my child in such postings.

Initial(Required)

Date(Required)

MM slash DD slash YYYY

IN THE EVENT OF AN EMERGENCY(Required)

I Consent

In case of an accident considered “major” by the school, your child will be sent to the Emergency Room, if necessary. Please be advised that TIES does not assume responsibility for emergency medical treatment, payment of physician’s fees, or health expenses of students who are injured at school or at school-sponsored activities away
from the school campus.

Initial(Required)

Date(Required)

MM slash DD slash YYYY

ACKNOWLEDGEMENT

By signing this form, I acknowledge receipt of this information, confirm the information I provided is true and accurate, and confirm this document supersedes any previous information given to TIES.

Name of Person Completing Form(Required)

First Last

Relationship to student(Required)

Date(Required)

MM slash DD slash YYYY

Signature of Person Completing Form(Required)

Please print full name

(If Person Financially Responsible is different from, please continue below)

Name of Person Financially Responsible

First Last

Relationship to student

Date

MM slash DD slash YYYY

Signature of Person Financially Responsible

Please print full name

How did you find out about TIES?(Required)

Want to keep up-to-date with our latest news and announcements?

Yes please!

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TIES REVERE - 2026