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Parent/Guardian's name*:

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Student's Email*:


Date Expected to Report at the Studyville*:

Hospital Name*:

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Student's Name*:

Institution Student is Admitted at*:

Date Expected to Complete course*:

Doctor's Name*:

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I confirm that I will be responsible for paying the accommodation fee for my son/daughter/Scholar if he/she is admitted to KAFOCA-MUKURU Studyville. And if he/she falls sick and requires urgent medical attention, I would request you to take him/her to the following doctor/hospital. I comply to the terms and conditions*:


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