Medical Permission Form For Grandparents
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Medical Permission Form For Grandparents

Participation in school activities athletics emergency medical form
PARTICIPATION IN SCHOOL ACTIVITIES/ATHLETICSEMERGENCY MEDICAL FORMForm No.2003 Date: August 2011 Policy: 2930 Page 1 of 1 Name:

Sports:

Yes No Date:

Parent Signature:

Student Signature:

This form, along with a physical, must be completed and returned to the appropriate coach prior to participation in athletics including practices
medical permission form for grandparents
.STUDENT INFORMATION

Student Name:

Class: Freshman Sophomore Junior Senior Last First Male Female Birth , Phone:

Mother & Father Father & Stepmother Father only Grandparents Guardian Mother & Stepfather Mother only

MEDICAL health problems that may affect your child in any way :(please state condition and kind of medical care he/she is receiMedications:

Does your student wear glasses? Yes No Yes No Hospital preference in case of emergency:

(The nature of injury or location of play may preclude this preference.) Insurance Company:

HMO PPO NA Policy/I.D.Number:

Insurance coverage is with: Mom Other

Yes No DATE:

PARENTS SIGNATURE:.
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