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Student Details :
Parents / Guardian Details :
Address :
Medical :
Does the student suffer from any serious or long-term illness, e.g. Epilepsy, Bronchitis etc?
Yes No   If ‘Yes’ please give details
Does the Student require any special (educational or other) needs?
Yes No   If ‘Yes’ please give details
Does the Student suffer from any allergies?
Yes No   If ‘Yes’ please give details
If required the following can be administered to the student
1. Paracetamol  
2. Antihistamine  
3. Over the Counter (OTC) drugs  
4. Please consent following
  1. Does Student Know Swimming  
  2. Travel sickness  
  3. Travel Permission  
  4. Photo Permission  
Islamic Education History :
Already attended islamic education   Yes No   If yes please provide details below
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