[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

(Form number 2)

In the Name of God,

 

Student and Parent/Guardian Information Form

 

[Note on the top of the page]

This form is prepared for inclusion in the student’s academic file and in the event urgent contact with his/her parents is required.

 

  1. Student details:

Given name: Amin    Surname: Mobin

Father’s Name: Iraj

Birth Certificate Number: [redacted]

Place of Issue of the Birth Certificate: [redacted]

Date of Birth: Date: 17 Month 09 Year [?]

Religion: Muslim ------   Christian ------ Jewish ------ Zoroastrian ------

Religion is Baha’i faith

Name of the school in the past academic year: ------

Address of the school in the past academic year: ------

Student’s grade, in the past academic year: ------

Branch of Education: ------

 

 

  1. Guardian Details:

Given name: Iraj

Surname: Mobin

Father’s Name: Naser

Birth Certificate Number: [redacted]

Date of Birth: ------

Level of education: ------

Relationship with the student: Father ------ Mother ------ other relatives ------ describe your Relationship with the student.

Parent’s occupation: Self-employed

Accurate address of the parent: [address redacted]

Please notify the school immediately of any change of address

Please answer the following questions accurately:

In view of your background and history, what issues or problems does your child have about which the school should be informed?

  1. From an academic viewpoint:
  2. From physical and health viewpoint: has allergy
  3. From a moral viewpoint:

 

Signature of the parent [Signature]

 

[Handwritten note at the bottom of the page]

As he confessed to being a Baha’i, [he] cannot be enrolled

[Signature]