PARENTAL CONSENT AND MEDICAL AUTHORIZATION

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Permission for:  *
First and last name of a minor(s) *
Grade Level *
Age: *
Street Address:
Cell Phone Number: *
Alternate Contact Person & Relationship to minor & Contact Number
Insurance Company
*
Policy/Group Number #
*
Doctor's Name
Doctor's Phone Number *
Pre-existing or present medical conditions? *
Name of Medications & dosage minor is currently taking: 
*
Date of last tetanus shot
*
MM
/
DD
/
YYYY
Allergies?
*
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