Grove Avenue Baptist Church Students Medical Release
Email address *
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Student Email (If no student email please put guardian email) *
Your answer
Student Phone (If no student phone please put guardian phone) *
Your answer
Address - Street *
Your answer
Address - City and State *
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Zip Code *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Grade *
School *
Your answer
Member of Grove Avenue Baptist Church *
Parent/Guardian Information
Parent/Guardian Name *
Your answer
Parent/Guardian Phone *
Your answer
Parent Email *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Cell Phone *
Your answer
Other Emergency Contact (s) - please include contact cell phone number (s)
Your answer
Health Insurance Information
Insurance Company (If your child does not have medical insurance please type NONE) *
Your answer
Insurance Carrier Phone Number for Emergencies *
Your answer
Policy Holder *
Your answer
Policy ID #/Group # *
Your answer
Family Physician Name
Your answer
Family Physician Phone Number
Your answer
Medical History (Check all that apply to your student) *
Required
Allergies or Other medical concerns
Your answer
Medication (Include medication, name, dose, frequency and reason for each)
Your answer
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