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SEN Application Form

Fields marked with an * are mandatory.

Part 1 - Student Details

Student Name *

First

Last

Gender *

Male
Female

Date of Birth *

Age

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Landline *

Part 2 - Parents/Carers Details

Father's Name *

First

Last

Phone *

Email *

Mother's Name *

First

Last

Phone *

Email *

Primary contact *

Father
Mother
Other

Emergency Contact 1 (This must be different to contacts already provided previously)

Name *

First

Last

Relationship to student *

Phone *

Email *

Emergency Contact 2

Name *

First

Last

Relationship to student *

Phone *

Email *

Medical History (Include diagnoses) *

Actions in an emergency; please state any known procedures or actions if a medical emergency occurs *

Does the student have any allergies or special dietary needs? *

Other important information

Name and address of Doctor

Doctors telephone number

Part 3 - Schools Attended

Name

Date *

Name

Date

Name

Date

Part 4 - Madrasah

Please specify if the student had previously attended a Madrasah *

Yes
No

If student had attended a Madrasah(s) previously, please specify what had the student learnt?

Dua's

Surats

Kalimahs

Qaidah/Quran

Other Islamic books studied? e.g. Tasheelul fiqh etc

Part 5 - Current Ability Questionnaire

Please answer the following on a scale of 1-10 (10 being the highest)*

Understanding of commands. e.g. do you need the toilet *

Additional Comments

Motor Skills - ability of student to hold a pen or other objects: *

Additional Comments

Writing Skills: *

Additional Comments

Reading Skills: *

Additional Comments

Verbal Communication: *

Additional Comments

Mobility: *

Additional Comments

Part 6 - Upload Important Documents

Please email the following documentation or request the school/college to email a copy of the documents to bilalacademy@hotmail.co.uk

Documents requested:

Educational Psychologist Report
Statement/IPRA/EHCP
Medical Report
Annual Review
Health or other professional reports e.g, Physio, SALT
Students Photograph

Please note failure to provide the relevant document is likely to delay the processing of this application

Ethnicity

Indian
Pakistani
Bangladeshi
Arab

If other ethnicity, please specify

Please use the space below for any other additional information that you think may be relevant

Is consent given for the use of photography and promotional purposes? *

Yes
No

Would you like to be added to the Parent's WhatsApp group? (forum for Parent's to share tips, useful information and support network) *

Yes
No

If Yes, please provide the following information (if applicable)

Name *

First

Last

Phone

Name *

First

Last

Phone

Home
About Us
Islamic Education
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