March for Life 2018 ONLINE MEDICAL form
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Student Last Name
Student First  Name
Seat mate (same sex)
Student Cell Phone Number
Student email address
Please list any food allergies
Parent Name(s)
Parent Phone Number 1 (Cell)
Alternative Emergency Contact Number
Parente email address
In the event of an emergency, if I cannot be reached, please contact the following persons/phone numbers:
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:
Please identify any current medical conditions that may affect your child's participation in the trip:
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
Date
Drug Allergies
Health Insurance Company
Name of Insured
Member ID/Policy Number
Employer of Insured
Alternative Contact Number
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