Tel: +27 (0)33 343 3301 | NPO No. 067-749 | PBO No. 930022978 | Section 18A Compliant

First Name / s
Middle Name / s
Date of birth
Identity Number
Passport Number
Date of Issue
Date of Expiry
Marital Status
Country of Origin / Birth
Country of Residence
Preferred Language of Communication
Section B: Contact Information
Physical Address
Address Line 1
Address Line 2
Postal Code
Postal Address
Address Line 1
Address Line 2
Postal Code
Contact Numbers
Home Number
Mobile Number
WhatsApp Number
Email Address
Section C: Education
Islamic Education
Last Madrassa Attended
Last Grade Completed
Are You Able to Recite the Qur'an
How Many Ajzā (Chapters) Have you Completed
Have you memorised any portion of the Qur'an
If yes, please specify how many Ajzā you have memorised
Secular Education
Level of education
Name of last institute enrolled at
Last grade completed
Can you read Braille
How many languages can you read Braille in (Please list the top three)
Are you computer / technology literate
Which devices are you capable of using?
Section D: Medical
Visual Impairement
If other, please give details
What is the nature or degree of Visual Impairment?
How did you lose your vision?
If due to trauma or illness, please give details
Are you a registered blind person?
If yes, please provide your registration number
Do you have any other disability besides visual impairment?
If other, please specify
Please provide any additional details that we should be aware of
Section E: Family
Parents / Guardians
Fathers / Guardians First Name
Fathers / Guardians Surname
Fathers / Guardians Occupation
Mothers / Guardians First Name
Mothers / Guardians Surname
Mothers / Guardians Occupation
Primary Contact
Please Indicate your Primary Contact Person
Primary Contact's WhatsApp Number
Emergency Contact
Telephone (Mobile)
Telephone (Other)
WhatsApp Number
Email Address
Section F: Fees and Declaration
Please Select a fee Option
If you are unable to pay the fee and would like to apply for a bursary, please request a Bursary application form.
If you are able to pay the full fee, please complete the Fees Declaration below
Fee Declaration
Agreed Fee
Student Declaration
Declaration by Parent / Guardian for a Minor
First Name
ID Number
Section G: Consent and Indemnity
First Name
Physical Address
As the Parent / Guardian of
First Name
I hereby acknowledge the following regarding my child's/ward's attendance at Madrassa An-Noor for the Blind:
Supporting Documentation
Please upload the following documentation
Passport / ID Photo
Maximum file size: 128 MB
Copy of Passport / ID
Maximum file size: 128 MB
Parent / Guardian's Passport / ID Photo
Maximum file size: 128 MB