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Islamic Community School

Primary Education Program — Enrollment Application 2026-27

School Year 2026–2027

7238 Nathan Court, Manassas, VA 20109   •   (571) 379-8983   •   school@manassasmosque.org   •   www.myics.school

Child Information #1

Last Name

First Name

Middle Name

Preferred Name

Date of Birth

Gender

Gender
A
B

Age

Primary Language Spoken at Home

Primary Care Physician

Doctor's Phone

Does your child take any medication regularly?

Does your child take any medication regularly?
A
B

Does your child require medication during school hours? If yes, list medication name and dosage:

Allergies & Dietary Needs

Does this child have any known food allergies?

Does this child have any known food allergies?
A
B

If yes, please list:

Does this child have any non-food allergies (environmental, medication, etc.)?

Does this child have any non-food allergies (environmental, medication, etc.)?
A
B

If yes, please describe:

Dietary Restrictions:

Dietary Restrictions:

If other, specify:

Does this child carry an EpiPen or require emergency medication?

Does this child carry an EpiPen or require emergency medication?
A
B

If yes, please describe:

Developmental History

This information is confidential and used solely to support your child in the classroom.

Is this child currently receiving or has previously received therapy services?

Is this child currently receiving or has previously received therapy services?
A
B

If yes, check all that apply:

If yes, check all that apply:

Has this child been evaluated for or diagnosed with a developmental delay or disability?

Has this child been evaluated for or diagnosed with a developmental delay or disability?
A
B

If yes, please describe (optional):

Describe your child's developmental strengths:

Describe any areas of concern or challenges:

Anything else we should know? (temperament, routines, comfort items, etc.)

Parent / Guardian Information

Mother / Guardian 1

Full Name

Relationship to Child

Home Phone

Cell Phone

Email Address

Home Address

City

State

ZIP Code

Employer/Organization

Work Phone

Work Address

Father/Guardian 2 (if applicable)

Full Name

Relationship to Child

Home Phone

Cell Phone

Email Address

Home Address (if different from above)

City

State

ZIP Code

Employer/Organization

Work Phone

Work Address

Custody & Legal Arrangements

Are there any custody agreements or court orders that affect pickup or contact with your child?

Are there any custody agreements or court orders that affect pickup or contact with your child?
A
B

If yes, please describe and attach documentation if available:

ICS is required to follow all valid court orders. Please provide a copy of any relevant legal documents.

Please upload any documentation here for custody and legal arrrangments

Authorized Pickup List

Children will ONLY be released to the parents/guardians above or the individuals listed below. A valid photo ID is required at pickup.
Authorized Person 1

Full Name

Relationship to Child

Primary Phone

Secondary Phone

Authorized Person 2

Full Name

Relationship to Child

Primary Phone

Secondary Phone

Authorized Person 3

Full Name

Relationship to Child

Primary Phone

Secondary Phone

Agreements & Consent

Please read each section carefully and sign where indicated. All signatures are required to complete enrollment.

1.  Tuition & Payment Agreement

I/We agree to pay the monthly tuition as outlined above by the 1st of each month. I/We understand that a $25 late fee applies after the 5th and that tuition is non-refundable once the enrollment period has begun.

Parent/Guardian Signature

Date

2.  Photo & Media Release

We/I, are aware that our child/ren's pictures will be taken by the staff, and possibly other parents, at Islamic Community School. These pictures may be used in masjid/school-related publications including the mosque and school's website, social media outlets, brochures, slide presentations, emails and on hallway and bulletin boards.

I/We acknowledge and agree to the above picture/media policy.

I/We acknowledge and agree to the above picture/media policy.
Parent/Guardian Signature

Date

3.  Handbook Acknowledgment

I/We have received, read, and agree to abide by the ICS Parent & Student Handbook, including all policies regarding attendance, behavior, health, communication, tuition, and disenrolling.

Parent/Guardian Signature

Date

4.  Emergency Medical Authorization

In the event that I/we cannot be reached in an emergency, I/we authorize ICS staff to seek immediate medical care for my/our child as deemed necessary by emergency personnel.

Parent/Guardian Signature

Date

5.  Visit Manassas Mosque Disclosure

We/I are aware that our child/ren will go between Manassas Mosque and Islamic Community School during school hours while being supervised by an adult for the duration of the 2026-27 school year.

Parent/Guardian Signature

Date

6.  Play on Field Disclosure

We/I are aware that our child/ren will play on the field across the street from Islamic Community School during school hours while being supervised by an adult for the duration of the 2026-27 school year.

Parent/Guardian Signature

Date

Do you have another child you would to register for?

Do you have another child you would to register for?
A
B