Al Salaam Academy 9th Grade High School Application

Al Salaam Academy High School Application Form
بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
I. Applicant information
Student's Full Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Country of Birth*
Country of Citizenship*
SSN*
Gender*
Ethnicity*
Student's Phone Number
Please enter a valid phone number.
Student's Email
example@example.com
Current Grade*
Proposed Enrollment Grade*
Proposed Enrollment Date*
Optional Notes
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
III. Applicant's Educational History
Present School*
Type of School*

Private SchoolPublic SchoolOther
Present School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Principal Name*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
School Phone Number*
Dates of Attendance*
Other Schools Attended & Dates of Attendance (Past Three Years)*
Current Official Transcript

Cancelof
If transcript is unavailable, please list all current subjects and current grades.
Please check all applicable fields*

Student is enrolled in honors or advanced classesStudent has an educational psychological evaluationNone of the above
Special Learning Needs?*
Please list Volunteer activities, clubs, organizations, and athletic teams in which the applicant has participated during the past three years.

بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
IV. Recommendations

Please provide contact details for at least two sources of recommendation. At least one of the sources should be familiar with the student in an academic setting. Examples include a teacher, counselor or administrator who has worked with the student recently. The other source should be any adult (outside of family members) who can speak to the character of the applicant. By providing these contacts, you are giving permission for them to comment on the student's performance and their impressions of the student's strengths and weaknesses. Additional letters of reference are also welcomed.
Name of Academic Reference*

First NameLast Name
Title of Academic Reference*
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Name of Personal Reference*

First NameLast Name
Title of Personal Reference*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Additional Reference (Optional)

First NameLast Name
Title & Relationship to Applicant
Email & Phone Number of Additional Reference

بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
V. Applicant's Conduct History

Please answer each item below thoroughly to provide a full understanding of the applicant.
School Behavior*

Extended School AbsenceSchool SuspensionSchool WithdrawalNone of the above
Involvement with Legal Authorities*

NoYes
Please provide information on how comfortable the applicant is with their daily practice of Islam. *
Please provide any additional details that will help us better understand the applicant.

بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
VI. Applicant's Medical History

Al Salaam Academy requires that a completed immunization record and a medical information form signed by a physician be submitted by the first day of attendance. Documents will be provided upon notification of acceptance.
Name of applicant's primary healthcare provider
Healthcare provider's phone number
Has the applicant ever been diagnosed with a communicable disease? If yes, please provide details. *
Does the applicant have any medical conditions that could prevent participation in the school's physical education or athletic programs? If yes, please provide details. *
Please provide brief details on any hospitalizations in the applicant's history or write N/A if there are none. *
Please list any medications the applicant is currently taking or write N/A if there are none. *
Has the applicant ever received professional counseling?*

NoYes

VII. Document Uploads
Proof of Residence*

Cancelof

بسم الله الرحمن الرحيم

In the name of God, the extremely merciful, the eternally merciful.
VIII. Additional Information
How did you hear about Al Salaam Academy?*

School WebsiteSocial MediaWhatsapp GroupWord of MouthOther
[Male Students Only] If accepted, the applicant and parent(s) give permission for the applicant's photograph to be included in the school's publications, including, but not limited to, social media, email, etc.

Yes
If accepted, the applicant and parent(s) give permission for the applicant's photograph to be included in the school's publications, including, but not limited to, social media, email, etc. Initial below:*
As a legal guardian, I give permission to ASA to administer any emergency medical treatment. Initial below:*
As a legal guardian, I agree to all school policies as well as code of conduct policies. Initial below:*
Religious Affiliation
This information is requested to meet requirements of federal record-keeping purposes only. This information will in no way affect admission decisions.
Ethnicity
This information is requested to meet requirements of federal record-keeping purposes only. This information will in no way affect admission decisions.
Al Salaam Academy does not discriminate on the basis of religion, race, sex, or geographic origin. Please read carefully before signing and submitting:

I certify that I have read and understood this application, and I further certify that the information I have submitted is complete and correct to the best of my knowledge and belief. I agree to communicate to the Director of Admission in writing any changes in any matters contained herein even if such changes occur after the student has been enrolled. I understand that upon discovery of any inaccuracy of information contained herein, or omission of information requested herein, Al Salaam Academy reserves the right to revoke any admission to Al-Salaam Academy. I also give permission for Al-Salaam Academy to request student records from the student's current school.
Signature of Parent/Guardian*

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Date*

MonthDayYear
Date
Name of person(s) who will assume responsibility for payment of tuition and fees and their relationship to the applicant. *
Application Fee: $50

Please use Zelle to submit the Application Fee at info@alsalaamacademy.org. Application is not complete until the fee is paid in full.

If you have any questions, please contact us.

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Al Salaam Academy High School Application Form

بسم الله الرحمن الرحيم

I. Applicant information

بسم الله الرحمن الرحيم

II. Parent/ Guardian Information

بسم الله الرحمن الرحيم

III. Applicant's Educational History

بسم الله الرحمن الرحيم

IV. Recommendations

بسم الله الرحمن الرحيم

V. Applicant's Conduct History

بسم الله الرحمن الرحيم

VI. Applicant's Medical History

VII. Document Uploads

بسم الله الرحمن الرحيم

VIII. Additional Information

Al Salaam Academy does not discriminate on the basis of religion, race, sex, or geographic origin. Please read carefully before signing and submitting:

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