Admission No ^*

Student Class ^* Select Pre Primary Reception Nursery One Nursery Two Primary One Primary Two Primary Three Primary Four Primary Five Primary Six JSS One JSS Two JSS Three SS One SS Two SS Three

Tahfiz Select Enrolled Unenrolled

Sponsorship Type ^* Select Parent Foundation

Bus Services ^* Select Applicable Unapplicable

Student Picture ^*

Surname ^*

First Name ^* :

Other Name

Date of Birth ^*

Gender ^* Select Male Female

Religion ^* Select Islam Christianity Other

Special Needs ^* Select Yes No

if yes, specify

Home Address ^*

State of Origin ^* Select Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu FCT (Abuja) Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara

Title ^* Select Alhaji Mallam Mr Mrs Ms Dr Prof

Surname ^*

First Name ^*

Relationship ^* Select Father Mother Brother Sister Uncle Aunt Grandfather Grandmother Other

Occupation ^*

Address ^*

Email

Contact No ^*

Other Contact No

Title Select Alhaji Mallam Mr Mrs Ms Dr Prof

Surname

First Name

Relationship Select Father Mother Brother Sister Uncle Aunt Grandfather Grandmother Other

Occupation

Address

Email

Contact No

Other Contact No

Name of School

Start Date

End Date

Class Finished Select Pre Primary Reception Nursery One Nursery Two Primary One Primary Two Primary Three Primary Four Primary Five Primary Six JSS One JSS Two JSS Three SS One SS Two SS Three

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