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Leader Contact Information & Health Record
Please fill out all fields
Leader (middle school student)
First Name
Last Name
Leader Phone Number
Leader email
example@example.com
Name of Leader's School or Organization
Leader Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Parent/Guardian #1
First Name
Last Name
Phone Number of Parent/Guardian #1
Email of Parent/Guardian #1
example@example.com
Address of Parent/Guardian #1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Parent/Guardian #2
First Name
Last Name
Phone Number of Parent/Guardian #2
Email of Parent/Guardian #2
example@example.com
Address of Parent/Guardian #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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List any allergies
List/describe any physical challenges
Sex
Female
Male
Ethnicity
List Chronic/Recurring Illness
List Infectious Diseases
List Convulsive Disorders
Overall Health
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Next
Family Physician
Physician's phone number
Do you have Health Insurance? (If "yes", please answer the next two questions)
Yes
No
Health Insurance Company Name (please note that Hope College's policy is to send any emergencies to Holland Hospital regardless of your insurance)
Policy number
Family Dentist
Dentist's phone number
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Are all immunizations up to date? (Immunizations must be up to date in order to participate)
Yes
No
List Prescription Medication (include dosages)
Emergency Contact Daytime
Please enter a valid phone number.
Emergency Contact Nightime
Please enter a valid phone number.
Email
example@example.com
Submit
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