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Medical Authorization and Emergency Contact
We want to be prepared to serve all participants to the best of our ability and provide the best experience for all participants in and out of the classroom.

Relevant information may be shared with faculty, Residential Life, and dining services.

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Student Name *
First Name   Last Name
Student Email Address
Gender Identity *
Street Address *
Address Line 2
City, State, Zip *
Name of Parent/Guardian *
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