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Merch
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STUDENT HEALTH AND EMERGENCY CONTACT INFORMATION
Please complete the form below
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Kenosha Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell
*
(###)
###
####
Home
(###)
###
####
Work
(###)
###
####
Email
Vehicle Make and Model
License Plate Number
In case of an emergency, please contact the following person(s)
Primary Contact Name
*
Relationship To You
*
Primary Contact Address
*
Primary Contact Email
*
Primary Contact Cell
*
(###)
###
####
Secondary Contact Name
Secondary Contact Address
Secondary Contact Email
Secondary Contact Cell
(###)
###
####
Medical Information
Physician's Name
Physician's Address
Physician's Phone Number
(###)
###
####
Insurance Provider
Insurance Policy Number
Medical Conditions
Medications
Physical limitations
Allergies
Other helpful information
Thank you!
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