• Member Information

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  • Parent/Guardian Contact Information

  • Parent/Guardian #1

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  • Parent/Guardian #2

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  • Emergency Contact Information

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  • Member Medical Information:

  • IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT ME. IN THE EVENT THAT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE HOSPITAL AND ATTENDING PHYSICIAN SELECTED BY BLESSEDGIRL. TO TAKE ANY NECESSARY ACTION, INCLUDING SURGERY, ANESTHESIA, OR INJECTIONS, THAT IS IN THE BEST INTEREST OF MY CHILD.

  • MEDICAL DECLARATION STATEMENT FOR SCHOOL-AGE CHILD CARE

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  • As a parent/guardian of the above participating child, I certify that he/she is in good physical health, has no special needs, and may participating in all of the activities of the BLESSEDGIRL program, except as noted above.

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