Muslim Academy
EMERGENCY CARD 2024-2025    [Complete a separate form for EACH student attending Muslim Academy]
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Email *
Student FIRST Name *
Student LAST Name *
Student's Grade (for 2024-2025 school year)

*
STUDENT'S  Date of Birth *
Month/Day/Year
Home Address (house#, street, city, ZIP) *
Father's Full Name *
Father Contact Phone Number (format 123-456-7890)    *
Father Email Address *
Mother Full Name *
Mother Contact Phone Number  (format 123-456-7890) *
Mother Email Address *
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]
*
Phone number of Friend/Relative #1 (above)  
(format 123-456-7890)
*
Relationship of Friend/Relative #1 (above) *
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]
*
Phone number of Friend/Relative #2 (above)
(format 123-456-7890)
*
Relationship of Friend/Relative #2 (above) *
Student's Doctor
Doctor Phone
Student's Medications (List medications, if applicable, and any instructions we may need to administer if required)
Student's Allergies (List allergies, if applicable. Provide as much detail as possible)
Other Issues (please describe any special situations that may help us such as custody arrangements, chronic health conditions, disabilities, etc.)
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