EmailMe Form - American Muslim Preparatory Academy

Name
First Last
Email
Phone
### - ### - ####
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Emergency Contact
Name
First Last
Relationship
Phone
### - ### - ####
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Nation of Citizenship
Race / National Origin
Native Language
Religion
Gender
Male
Female
Date of Birth
MM / DD / YYYY
This application is for enrollment as:
Freshman
Sophomore
Jumior
Senior
Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution?
Yes
No
If yes, please explain.
Prior School Information
School Name and Location
School Phone Number
Highest Grade Completed