The Islamic Education School Annual Student Registration FormStudent InformationName(Required) First Middle Last Grade Level(Required) Birth Date(Required) MM slash DD slash YYYY Gender (Choose one)(Required)MaleFemaleLanguages 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 INFORMATIONNote: TIES sends school information and announcements via text/voice/email. Please complete all information accuratelyGuardian 1 Name(Required) First Middle Last Relationship(Required) Guardian 1 Email(Required) Guardian 1 Home PhoneGuardian 1 Work PhoneGuardian 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 PhoneGuardian 2 Work PhoneGuardian 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 sectionSTUDENT/PARENT PRIMARY ADDRESSAddress(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code SCHOOL HISTORYLast School Attended(Required) Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code EMERGENCY CONTACTEmergency Contact 1(Required) First Last Relationship to Student(Required) Phone(Required)Guardian Initial Initial Emergency Contact 2 First Last Relationship to Student PhoneGuardian Initial Initial Emergency Contact 3 First Last Relationship to Student PhoneGuardian Initial Initial HealthPhysician's Name(Required) First Last Physician's Phone(Required)Physician's Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 INFORMATIONDoes 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 NumberStep-mother’s Name First Last Step-mother’s Email Address Authorized To Receive School/Student Information Step-mother’s Phone NumberSTUDENT / PARENT SECONDARY ADDRESS (Skip if not applicable)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Media PermissionTIES 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 ConsentIn 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 ACKNOWLEDGEMENTBy 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 Signature of Person Completing Form(Required) Relationship to student(Required) Date(Required) MM slash DD slash YYYY (If Person Financially Responsible is different from, please continue below)Name of Person Financially Responsible First Last Signature of Person Financially Responsible Relationship to student Date MM slash DD slash YYYY How did you find out about TIES?(Required) Want to keep up-to-date with our latest news and announcements? Yes please!CAPTCHA
