Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Student Cell Phone

(###)

###

####

Parent #1 Name

First Name

Last Name

Parent #1 Cell Phone

(###)

###

####

Parent #1 Work Phone

(###)

###

####

Parent #1 Email Address

(###)

###

####

Parent #2 Name

First Name

Last Name

Parent #2 Cell Phone

(###)

###

####

Parent #2 Work Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

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Does the student carry an Epipen?

Yes

No

Minor is permitted to administer their own medications

Yes

No

Adults in charge may administer:

Please check any that you feel comfortable allowing an adult in charge to administer to your student.

Aspirin

Advil

Dramamine

Tylenol

Benadryl

Physician Phone Number

(###)

###

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