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Student Medical Release Form
I hereby give permission for my child to attend all MVCC events and receive any medical attention if necessary. Can be filled out for multiple students.
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Student Name *
Student Name
Student Name
Parent Name *
Parent Name
Date of Birth (and name) *
Date of Birth (and name)
Date of Birth (and name)
Address *
Parent Email *
Parent Email
Emergency Contact Name and # *
Emergency Contact Name and # *
Insurance Company *
Policy # *
For each child, please list any physical limitations, allergies, or significant medical history which may be needed in case of emergency.
List any medication that are currently being taken. Please include when medication was started or is ending if applicable.
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