Al Salaam Academy Tutoring Program Registration Form
In the name of Allah, the intensely merciful, the eternally merciful. Please fill out the form below and complete the registration fee to submit.
Student Info
Full Name
*
First Name
Last Name
Age
*
Gender
*
Please Select
Male
Female
Current School Grade
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tutoring Subjects
*
Please Select
Mathematics
English
Chemistry
What prompted you to seek tutoring?
*
Struggling in class
Preparing for a test
Just want to get ahead
Other
Parent /Guardian Info
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address if different from student address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Website
Social Media
Word of Mouth
Other
Registration Fee
*
prev
next
( X )
USD
Registration Fee
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
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