March for Life 2018 ONLINE MEDICAL form
Student Last Name
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Student First Name
Your answer
Seat mate (same sex)
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Student Cell Phone Number
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Student email address
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Please list any food allergies
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Parent Name(s)
Your answer
Parent Phone Number 1 (Cell)
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Alternative Emergency Contact Number
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Parente email address
Your answer
In the event of an emergency, if I cannot be reached, please contact the following persons/phone numbers:
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I authorize the trip nurse/chaperone to dispense to my child the following medications as needed:
The medicines brought by my child on the trip (OTC and Rx) include:
Your answer
Please identify any current medical conditions that may affect your child's participation in the trip:
Your answer
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. Type your name for a signature
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Date
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Drug Allergies
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Health Insurance Company
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Name of Insured
Your answer
Member ID/Policy Number
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Employer of Insured
Your answer
Alternative Contact Number
Your answer
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