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SECTION A – PERSONAL DETAILS

SECTION B – CONTACT INFORMATION

SECTION C – MEDICAL

SECTION D – EDUCATION

SECTION E – COURSE INFORMATION

FIRST NAME/S:*

SURNAME:*

DATE OF BIRTH:*

AGE:*

GENDER:*

Male
Female

MARITAL STATUS:*

Single
Married

PHYSICAL ADDRESS:

POSTAL CODE:

COUNTRY:

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe

POSTAL ADDRESS:

POSTAL CODE:

COUNTRY:

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe

TELEPHONE HOME:

TELEPHONE MOBILE:*

EMAIL ADDRESS:*

TYPE OF VISUAL IMPAIRMENT:

Blind
Partially Sighted
Other

VISION LOSS – OTHER

HOW DID YOU LOSE YOUR VISION:

Birth
Trauma
Illness

TYPE OF TRAUMA/ILLNESS:

TYPE OF TRAUMA – OTHER

DO YOU HAVE ANY OTHER DISABILITY BESIDES VISUALLY IMPAIRMENT:

Cerebral Palsy
Deaf
Intellectually Challenged
Mute

DISABILITY – OTHER

NAME OF LAST MADRASSA ATTENDED:

LAST MADRASSA GRADE COMPLETED:

YEAR:

NAME OF LAST SCHOOL ATTENDED:

LAST SCHOOL GRADE COMPLETED:

YEAR:

CAN YOU READ BRAILLE:

IF YES:

Grade 1
Grade 2
Both

BRAILLE LANGUAGES:

English Braille
Arabic Braille
Both

WHAT OTHER LANGUAGES CAN YOU READ IN BRAILLE:

DO YOU USE LARGE PRINT:

SIZE OF PREFERRED FONT (POINT):

HOW MANY CHAPTERS (JUZ) OF THE HOLY QUR’AN HAVE YOU COMPLETED THROUGH MEMORIZATION:

LIST CHAPTER NUMBERS:

HOW MANY SURAHS OF THE HOLY QUR’AN HAVE YOU COMPLETED THROUGH MEMORIZATION:

LIST SURAH NAMES:

WHICH ONLINE COURSE WOULD YOU LIKE TO STUDY:

Qur’an
Noorul Qur’an
Surahs
Duas
Hadith

PREFERRED ONLINE PLATFORM:

Whatsapp
Zoom
Skype
Other

PREFERRED DAY FOR ONLINE CLASS:

Monday
Tuesday
Wednesday
Thursday
Friday

TIME:

PREFERRED LANGUAGE OF COMMUNICATION:

HOW WERE YOU REFERRED TO MADRASSA AN-NOOR FOR THE BLIND:

Website
Ulama
NGO
Welfare Organisatoin
Directly
Other

PLEASE ADD ANY FURTHER QUESTIONS OR COMMENTS YOU WOULD LIKE TO SHARE:

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