Salam Academy Student Registration
To Enroll your child in Salam Academy Fill out this form. All Questions are REQUIRED
Email *
Student Full Name( First, Last, Middle) *
DOB *
MM
/
DD
/
YYYY
Gender *
Grade enrolling in *
Full Address (City, State, Zip Code)
Place of Birth (City, State, Country) *
Name of Last School Attended (City, State, Country) *
Has your child ever been suspended for aggressive behavior? *
Has your child EVER been expelled *
Has your student ever repeated a grade? *
Special Programs Check all that apply *
Required
Residence: Where is your child/family currently living? *
Student lives with (check only one) *
Is a custody order in place *
Parent/Guardian Full Name *
Home/Cell Number and Carrier (ATT, TMobile etc) *
Parent/Guardian Full Name (if none type none)
Home/Cell Number and Carrier (ATT, TMobile etc)
Parent/Guardian Full Name (if none type none)
Home/Cell Number and Carrier (ATT, TMobile etc)
Emergency Contacts Name, Relationship to Student, Cell Phone Number *
Emergency Contacts Name, Relationship to Student, Cell Phone Number
Emergency Contacts Name, Relationship to Student, Cell Phone Number
IN CASE OF EMERGENCY IF I OR THOSE DESIGNATED CANNOT BE REACHED, I GIVE PERMISSION FOR MY CHILD TO RECEIVE EMERGENCY MEDICAL TREATMENT *
Student Doctor's Name and Phone *
Next
Never submit passwords through Google Forms.
This form was created inside of Salam Academy. Report Abuse