Students First Name (required)

Students Surname (required)

Students Date of Birth (required)

Students Gender (required)
MaleFemale

Students Email (required)

Please leave this field empty.

Does the student have any medical needs/ learning needs? If yes please state.
YesNoPrefer not to say

Address Line 1 (required)

Address Line 2

Postcode

Students Contact Number (required) (If Student is under 18 please provide a parents number instead)

Where did you hear about us? (required)
LeafletSignboardFriendReferralWebsite SearchSchoolSocial Media
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Parents Details (If student is under 18)
Parents First Name

Parents Surname

Parents Contact Number

Parents Date of Birth

Gender
MaleFemale

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Please Select your preferred timeslot for your class. This is your preference, we will try to accommodate as much as possible.
4pm-6pm5pm-7pm6pm-8pmAfternoon

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We would like your consent to take photos and videos of the live sessions and use them for promotional materials.  If you are not happy for us to do this, we will accommodate your preferences and blur your video. If you are happy for us to do this please tick the box below.

I am happy for Al-Bashir Academy to take photos/videos for the reasons stated above.

I give consent for you to store my data and contact me when needed.

I can confirm I have read and accepted the Terms and Conditions.

Promotional Code