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Health declaration

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

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Clara Mohammed School, Inc. does not discriminate on the basis of race, color, creed, national or ethnic origin in its admissions policy or in the administration of its educational policies, scholarships, athletic, or other school-administered programs.

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