Faith Lutheran Church Medical Release & Permission Form 2024-2025
Effective dates: June 15, 2024-June 14, 2025
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Student Name (First, Middle, Last) *
Student Birthdate *
Student Email
Student Cell Phone
Parent/s' or Guardian/s' Name *
Parent/Guardian Email *
Parent/Guardian Cell Phone/s *
Medical Insurance Company *
Insurance Identification # *
Insurance Group #
Physician *
Physician Phone # *
Dentist  *
Dentist Phone # *
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