Health History and Medical Release Form
For Parish events and activities in the 2018-2019 School Year. Complete one form per child. Have your child's health insurance information accessible before completing this form.
Last Name *
Your answer
First name *
Your answer
Sex *
Birthdate *
MM
/
DD
/
YYYY
Grade *
Parent/Guardian *
Last Name
Your answer
*
First Name
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Home Phone
555-555-5555
Your answer
Parent Cell Phone *
555-555-5555
Your answer
Parent Work Phone
555-555-5555
Your answer
Parent Email *
Your answer
Participant's Cell Phone
555-555-5555
Your answer
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