There Gist Form Jpm Logo

JPM Sengkang (Al-Mawaddah Mosque) 151 Compassvale Bow Sengkang Central Post Office P.O Box 861 S (915408) Fax: 6384 0403

aL.I.V.E. at Al-Mawaddah Mosque REGISTRATION FORM Please indicate  for Programme, Year and Session: KIDS aL.I.V.E.  TEENS aL.I.V.E.  TWEENS aL.I.V.E.

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YOUTH aL.I.V.E.

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Holiday Programme …..  Academic Programme …..  Year 1 ……. Monday ……. Session: Year 2 ……. Tuesday ……. Year 3 ……. Wednesday.. 7.45am – 10.45am..  Year 4 ……. Thursday……  11.00am – 2.00pm… Saturday ……. 2.15pm – 5.30pm … 

CHILD’S PHOTO

*Please include a copy of Child’s Birth Certificate/NRIC and Parents’ NRIC. (A) CHILD’S PARTICULAR FULL NAME IN BLOCK LETTERS: __________________________________________________________________________________ __________________________________________________________________________________ Birth Cert/NRIC No.: ___________________ Birthdate: _____/_____/_____ Citizenship : __________________________

Female  Male 

Race : ______________________________________

Residential Address : ________________________________________________________________ __________________________________________________________________________________ ________________________________________________ Postal Code: _____________________ Home No.: ________________ School Attending : _______________________________________ Islamic Education classes attended previously: _______________________ Level: _______________ (B1) PARENT’S PARTICULARS FATHER’S NAME: __________________________________________________________________________________ NRIC No. : ______________________ Citizenship : _______________________________________ Residential Address (if different from above) : ____________________________________________ ________________________________________________ Postal Code: ______________________ Home No.: ________________ Mobile No.: ________________ Office No.: ___________________ Email Address: ______________________________________________________________________ Highest Education : ______________________ Occupation : _________________________________ LPM Al-Mawaddah . Masjid Yang Penuh Kasih Sayang . Love & Affectionate Mosque

(B2) PARENT’S PARTICULARS MOTHER’S NAME: __________________________________________________________________________________ NRIC No. : ______________________ Citizenship : _______________________________________ Residential Address (if different from above) : ____________________________________________ ________________________________________________ Postal Code: ______________________ Home No.: ________________ Mobile No.: ________________ Office No.: ___________________ Email Address: ______________________________________________________________________ Highest Education : ______________________ Occupation : _________________________________ (C) FAMILY PROFILE (i) GROSS HOUSEHOLD INCOME: (Please indicate  ) $1000 – below .….

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$2100 - $2500 …..  $3100 – $4000 ….. 

$1100 - $2000 …..  $2600 - $3000 …..  $4100 – above …..  (ii) TYPES OF RESIDENCE: (Please indicate  ) 2-3 Rooms …..  4 Rooms …..  (iiI) LANGUAGE PRIORITY :

5 Rooms ….. 

Private ….. 

Rent ….. 

(Please indicate 1/2/3 with 1 indicating most preferred/spoken) English ……  Malay ……  Others ……  Please state : _____________________ (iv) NUMBER OF CHILDREN IN HOUSEHOLD : ____________________ (v) NUMBER OF CHILDREN ATTENDING aL.I.V.E. : ________________________ (vi) PERSON (S) TO CONTACT IN CASE OF EMERGENCY: (Extended family member/Guardian) Name (1) : ________________________________________________________________ Relation to child : ___________________________ Contact No. : ____________________ Name (2) : ________________________________________________________________ Relation to child : ___________________________ Contact No. : ____________________ (vii) DECLARATION BY APPLICANT: I, __________________, hereby declare the information given is correct. ______________________

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Parent’s Signature

Date

FOR OFFICIAL USE Date of Submission : _____________________

Received by : _______________________________

Registration Fee : _______________ Education Fee : ______________ Monthly Fee : ___________ Receipt No. : _________________________ LPM Al-Mawaddah . Masjid Yang Penuh Kasih Sayang . Love & Affectionate Mosque