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ICCD ACADEMY

Islamic City Center of Deplaines
733 Lee Street Des Plaines, IL 60016

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REGISTER AS A VENDOR

Registration Form 2023-24 Academic Year

First Name

Last Name

Address

Birthday

What Grade(s) Are you applying for?

Pre-school 1/2 Day

Pre-School Full Day

Pre-K 1/2 Day

Pre-K Full Day

Kindergarten

1st Grade

2nd grade

3rd Grade

4th Grade

5th Grade

6th Grade GIRLS ONLY

7th grade GIRLS ONLY

8th Grade GIRLS ONLY

Mother's First Name

Email

Father's First Name

Email

How many members are in your household

2

3

4

5

6

7+

Annual Income Bracket

$30K or Below

$31K-$50K

$51K-$70K

$71K-$90K

$91K and Above

Mother's Last Name

Phone

Father's Last Name

Phone

Emergency Contact #1's Full Name

Relationship to Student

Phone

Emergency Contact #2's Full Name

Relationship to Student

Phone

Student's Birth Certificate

Upload File

Upload supported file (Max 15MB)

Immunization Records

Upload File

Upload supported file (Max 15MB)

Student Records/Transcripts (If applicable)

Upload File

Upload supported file (Max 15MB)

What Language(s) does your child(ren)speak?

English

Arabic

Russian

Urdu

Uzbek

Spanish

Kyrgyz

Other

How did you find out about us?

Thank you for registering in ICCD Academy

ICCD Academy

733 Lee Street

Des Plaines, IL 60016

224-567-8256

©2023 by ICCD Academy.

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