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Student Registration:

This is the Student Registration form of Qalam Collegiate Academy, please complete all the steps to for Successfully applying for admission.

We will get in touch with you once you finish your application submission.

#5 Health Information Section

Local Doctor's Name

Phone Number


My Daughter has Health Insurance


In the event that my daughter becomes ill or is injured at school and I cannot be reached, Qalam Collegiate Academy is authorized to contact the person(s) listed below, or Call 911 and transport my daughter to a hospital and is given consent for emergency care depending on the severity of the injury or illness. The Academy is NOT financially responsible for any emergency care and/or transportation.

Parent's Name

Student's Name

Relative of the Student

Phone Number

The Information Provided by me is correct

Digital Signature:

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Step 5 of 6

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