Islamic School – NMIC

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Child's Name

First

Last

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Date of Birth

Age

Years: 3

Grades Completed

Grade: 1

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Siblings Attending

Yes
No

Parents/Guardian's'Name

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

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Home Phone

Cell Phone

Email

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Special Needs/Allergies/Concerns

Child's Name of Consent

Parent's Name