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Consent for Medical Treatment
Student Last Name/Apellido Del Alumno *
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Student First Name/Nombre *
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Birthdate/Fecha De Nacimiento *
MM
/
DD
/
YYYY
Mother's Name/Nombre De La Madre *
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Mother's Phone Number/Telefono De La Madre *
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Father's Name/Nombre Del Padre *
Your answer
Father's Phone Number/Telefono Del Padre *
Your answer
Emergency Contact (Relative or Friend)/En Caso De Emergencia(Amigo O Pariente) *
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Emergency Hospital/Hospital De Emergencia *
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List of Allergies (Please type 'none' if the student doesn't have any)/Alergia Del Alumno *
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List of Medications (Please type 'none' if student doesn't have any)/Medicamentos Que Toma *
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Signature of Parent/Guardian(Please type your name below to signify that you accept all of the information listed above as correct)/Firma De Padre O Guardian *
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