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Muslim Academy
Emergency Card 2021-2022
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* Indicates required question
Email
*
Your email
Student Name (First and Last Name)
*
Your answer
Grade
*
Choose
PreKindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Date of Birth
*
MM
/
DD
/
YYYY
Home Address (house#, street, city, ZIP)
*
Your answer
Father's Full Name
*
Your answer
Father Contact Phone Number
*
Your answer
Father Email Address
*
Your answer
Mother Full Name
*
Your answer
Mother Contact Phone Number
*
Your answer
Mother Email Address
*
Your answer
Friend/Relative To Whom Student May Be Released
*
Your answer
Phone number of Friend/Relative (above)
*
Your answer
Relationship of Friend/Relative (above)
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Choose
Aunt/Uncle
Brother/Sister
Grandmother/Grandfather
Cousin
Friend/Neighbor
Employee/Co-worker
Student's Doctor
*
Your answer
Doctor Phone
*
Your answer
Student's Medications (List medications, if applicable)
Your answer
Student's Allergies (List allergies, if applicable.)
Your answer
Other Issues (please describe)
Your answer
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