Application Form ~ MOHID ©

Central Illinois Mosque and Islamic Center

106 S Lincoln Ave., Urbana, Illinois 61801, USA

School

Application Form

1. Parent(s) Information

2. Student(s) Information

3. Admission Form

4. Confirmation

Primary Parent Info:

First Name *

Last Name *

Email Address * All communication will be to this email address.

Confirm Email Address * Retype the email address to avoid the typing mistakes.

Phone Number *

Cell Number

Address1 *

Address2

Country *

State *

City *

Zip Code *

Add Second Parent Information

First Name *

Last Name *

Email Address * All communication will be to this email address.

Confirm Email Address * Retype the email address to avoid the typing mistakes.

Phone Number *

Cell Number

Same as Primary Parent Address

Address1

Address2

Country

State

City

Zip Code *

This Parent record already exists in the system. To submit new enrollment application(s) you can also login to Parent Portal

This Parent record already exists in the system with INACTIVE status. In order to enroll students(s), please contact school administrator to make parent record ACTIVE

Schools *

Add Previous Filled Person/Applicant as Student

First Name *

Last Name *

Student Photo

Dimension: min 120 px height

Type: jpg, jpeg, png

Size: Max 2 MB

Max. File Allowed: 1

Uploaded File

Student(s) Information

Gender

Age

Date of Birth

Previous School*

Emergency Contact No

Medical Needs Allergies, etc.

Important Document(s)

Type: pdf,doc,xlx,.jpg,.jpeg,.png

Max. size: 2MB (2,048 KB)

Max. Files Allowed: 5

Drop files here or click to upload.

Uploaded Files

Link

+ Add Another Student

Select School Academic Session * Note: Before Grade selection, select the School Academic Session in which you want to enroll the students.

Click here to view complete School Calendar.

Admission Form

Selected Grade * Note: Please select the Preferred Grade in which you want to enroll student. After submission, Administrator can change the Grade selection if required.

Select Student(s): *

Grade Information

+ Add Another Grade

Before submission, please review the provided information to avoid typing mistake(s).

Student(s)

Admission Form

Preferred Grade(s)	Student(s) With Admission Form Details

Fee Payment Details

Title(s)	Student(s) Details with Fee Types

Payment Information

Payment Method

eCheck/ACH

Credit Card

Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Consent * Do you give CIMIC Weekend School consent to authorize electronic fund transfer from the account specified for this transaction and any future transactions in the amount(s) specified until explicitly revoked or cancelled.

Agree Decline

Activate Auto Payment

Automatically pay invoice(s) on their due dates.

Default Payment Method

Use this as default payment method.

Total Amount *

No Payment Required at this time.

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Central Illinois Mosque and Islamic Center

School

Application Form

Primary Parent Info:

Drop files here or click to upload.

Student(s) Information

Drop files here or click to upload.

Admission Form

Grade Information

Student(s)

Admission Form

Fee Payment Details

Payment Information

Masjid Support

Central Illinois Mosque and Islamic Center