2018-2019 CMM Pep Squad Emergency Information
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Student Last Name *
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Student First Name *
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Address *
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City *
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Zip Code *
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Mother's Name *
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Father's Name *
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Mother's Phone *
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Father's Phone *
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Preferred Email *
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Emergency Contact Name *
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Emergency Phone Number *
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Student's Doctor *
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Doctor's Phone Number *
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Insurance Company *
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Insurance Policy Number *
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Medications (if any)
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Allergies (if any)
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Are there any medical conditions we should be aware of? If so, are there any procedures we should be familiar with?
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