Muslim Academy Emergency Card 2020-2021
Student will be released only to those persons listed on this form!
Please complete a form for each of your children attending Muslim Academy this year.
Student Name (First, Middle, Last) *
Birthdate *
MM
/
DD
/
YYYY
Grade *
Address (house #, Street, Apt#, City, State, ZIP) *
Father/Guardian Name *
Father's Phone# (xxx) xxx-xxxx *
Father's Email Address *
Mother/Guardian Name *
Mother's Phone# (xxx) xxx-xxxx *
Mother's Email Address *
Friend/Relative who may be called if my child becomes ill or injured (First and Last Name) *
Friend/Relative's Relationship to my child *
Phone# of Friend/Relative (xxx) xxx-xxxx *
Doctor's Name
Doctor's Phone# (xxx) xxx-xxxx
Does this student require medication? *
Required
Please list Allergies
Please describe other medical issues
Submit
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