Registration Form - Al Qalam Academy

Parent Account Details

Please enter information about parent or legal guardian responsible for the child-student.

Parent Name *

First

Last

Email *

Phone *

Parent's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Student Account Details

Please enter information about the student attending the online training program.

Student Name *

First

Last

Student Email *

This EMAIL will be used for ALL class activities.

Phone *

If does not have own, add parents phone.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Student's Educational History Information

We need some info on the prior student's school activity.

Last Grade Level Completed *

Last School Attended

School name.

School Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

From Date

To Date

Student's Additional Information

Has the student ever received severe disciplinary censure at any school or from the community? *

Yes
No

Has the student ever been suspended from school? *

Yes
No

Has the student ever been expelled from school? *

Yes
No

Which Grade You Are Enrolling In?

Kindergarden OR 1-12 OR 12 with college preparation

Enrolling into: *

Kindergarten
1-12 grade

Grade you are enrolling into: *

You want to attend: *

Full Time ?
Individual Classes ?

For attending school

Select classes you are interested in to attend:

Check all that apply

If you are enrolling into 9th grade, you MUST be 14+ YEARS OLD. Check below to indicate you understand this requirement. *

I understand

LEGAL DISCLAIMER

The undersigned have read and understand this application and certify that the information is complete and accurate to the best of your knowledge. The undersigned agree to communicate in writing any changes contained herein to the Office of Admission. The undersigned understand that upon discovery of inaccuracy or intentional omission of information requested herein, Al-Qalam Academy reserves the right to revoke admission.

I have read and agree with the school policy *

Read and agree

You must agree to this policy in order to use our services.

Parent Signature

Please sign here (parent or legal guardian):