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Print this form out and mail to:


One Madina Drive, P.O. Box 624, Windsor, CT. 06095

(860) 524-9700


If you are interested in sending your child to Madina Academy please provide us with the following information. Submit your completed form by mail or return it to the Masjid (Drop Box).

Fatherís Last Name First Name

Motherís Last Name First Name

Street Address

Town/City State Zip Code

Telephone: Home Office

Childís Last Name First Name

Childís Date Of Birth Male / Female


Has the child previously attended a school? Yes / No


If yes, please state the name of the school:


If yes, what grade level has the child completed?


In which grade do you plan to enroll your child? Kindergarten / Grade 1 / Grade 2 / Grade 3.

Please note that financial assistance is available for families who are having difficulty in paying the fees.