JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Muslim Academy
EMERGENCY CARD 2024-2025 [Complete a separate form for EACH student attending Muslim Academy]
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student FIRST Name
*
Your answer
Student LAST Name
*
Your answer
Student's Grade (
for 2024-2025 school year
)
*
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
STUDENT'S Date of Birth
*
Month/Day/Year
Your answer
Home Address (house#, street, city, ZIP)
*
Your answer
Father's Full Name
*
Your answer
Father Contact Phone Number (format 123-456-7890)
*
Your answer
Father Email Address
*
Your answer
Mother Full Name
*
Your answer
Mother Contact Phone Number (format 123-456-7890)
*
Your answer
Mother Email Address
*
Your answer
Friend/Relative #1 To Whom Student May Be Released in case of illness or emergency
[Student will only be released to those identified on this Emergency Card]
*
Your answer
Phone number of Friend/Relative #1 (above)
(format 123-456-7890)
*
Your answer
Relationship of Friend/Relative #1 (above)
*
Choose
Aunt/Uncle
Brother/Sister
Grandmother/Grandfather
Cousin
Friend/Neighbor
Employee/Co-worker
Other
Friend/Relative #2 To Whom Student May Be Released in case of illness or emergency
[Student will only be released to those identified on this Emergency Card]
*
Your answer
Phone number of Friend/Relative #2 (above)
(format 123-456-7890)
*
Your answer
Relationship of Friend/Relative #2 (above)
*
Choose
Aunt/Uncle
Brother/Sister
Grandmother/Grandfather
Cousin
Friend/Neighbor
Employee/Co-worker
Other
Student's Doctor
Your answer
Doctor Phone
Your answer
Student's Medications (List medications, if applicable, and any instructions we may need to administer if required)
Your answer
Student's Allergies (List allergies, if applicable. Provide as much detail as possible)
Your answer
Other Issues (please describe any special situations that may help us such as custody arrangements, chronic health conditions, disabilities, etc.)
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Muslim Academy .
Report Abuse
Forms
