Student Release/emergency Contact Form - Al Huda Academy

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Al Huda Academy
5104 Revere Road,
Durham, NC 27713
(919) 572-9500
STUDENT RELEASE/EMERGENCY CONTACT FORM
Date: ________________________
Phone Number_______________________
____________________________________________________________________________________________________
Last Name
First Name
Middle Name
____________________________________________________________________________________________________
Grade
Date of Birth
Teacher
Home Address: ______________________________________________________________________________________
____________________________________________________________________________Sex_____________________
Your child will be dismissed via ______carpool ______walk-up
Parent/Legal Guardian:
Name___________________________________________Employer____________________________________________
Home Phone________________Cell Phone_________________E-mail__________________________________________
Parent/Legal Guardian:
Name___________________________________________Employer____________________________________________
Home Phone________________Cell Phone_________________E-mail__________________________________________
Please list the people you would like to be notified in case of emergency, including a local contact.
____________________________________________________________________________________________________
Name
Address
Phone
Relationship
____________________________________________________________________________________________________
Name
Address
Phone
Relationship
I/We hereby request the student named above be released from school, at times other then normal dismissal times
only to persons listed below. I/We understand the school will respond to only WRITTEN requests as per this Form.
Any changes to the form need to be written and submitted to the school administration.
Name________________________________Relationship__________________________Phone Number______________
Name________________________________Relationship__________________________Phone Number______________
Name________________________________Relationship__________________________Phone Number______________
Medical problems, medication needs, allergies etc.
Yes / No
(Please Specify)_______________________________________________________________________________________

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