Roots of Radiance Academy Application Form

Roots of Radiance Academy

Please submit one application for your family and include information for each child you wish to enroll.

Enrollment is not complete until your application has been reviewed and all required registration fees, materials fees, and tuition arrangements have been completed.

Parent / Guardian Information

Parent /Guardian Full Name *

Parent Email *

Parent Phone *

Preferred Method of Contact *

Home Address *

Parent / Guardian 2 Full Name

Phone Number

Preferred Method of Contact *

Children Information

Your Children *

Child 1

Child's Full Name *

Date of Birth *

Gender *

School Name *

School Type *

Current Grade *

Which program would you like to enroll your child in? *

Has your child previously attended an Islamic School, afterschool maktab, or an weekend program? *

Has your child previously studied Arabic? *

If yes, previous program/school name

Is there anything you'd like our instructors to know that would help us support your child's learning or overall experience?

Allergies (if none, please write "none") *

Medical Conditions (if none, please write "none") *

Does your child need medication for their medical condition? *

Medications (if none, please write "none") *

You can add up to 4 children per application.

Permission to Administer Emergency Care*

I authorize Roots of Radiance staff to seek emergency medical treatment for my child(ren) if I cannot be reached. I understand every reasonable effort will be made to contact me first.

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I acknowledge that I have read and agree to the above.

EMERGENCY INFORMATION

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Student *

AUTHORIZED PICK-UP

Authorized Person's Name *

Phone *

Relationship to Student *

Authorized Person's Name 2

Phone 2

Relationship to Student

PARENT/GUARDIAN CONSENT & ACKNOWLEDGEMENTS

Parent/Guardian Acknowledgements*

I certify that the information provided in this enrollment application is true, complete, and accurate to the best of my knowledge.
I understand that submission of this application does not guarantee enrollment. Admission is subject to program availability, eligibility requirements, and approval by Roots of Radiance Academy.
I understand that tuition, materials fees, and any other applicable fees will be due only after my child has been accepted into the program. Enrollment is not considered complete until all required fees have been received.
I understand that I am responsible for ensuring my child attends classes regularly, arrives on time, and follows the policies and expectations outlined by Roots of Radiance Academy.
I authorize Roots of Radiance Academy to contact me regarding my child's enrollment through email, phone, or text message.
I understand that Roots of Radiance Academy may photograph or record students during classes or events for educational, promotional, and nonprofit purposes. I understand that I may request in writing that my child not be included in photographs or videos. (Optional, depending on your media policy.)
I understand that my child is enrolling in an Islamic educational program and agree to support the Academy's mission, values, and code of conduct.

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I acknowledge that I have read and agree to the above.

I confirm that all information provided is accurate and complete.

This fee covers your family's application and is not refunded for children who aren't offered a place.

Secure payment. You'll receive a confirmation email after payment.