STRONGER 2020 MEDICAL/PERMISSION FORM
Name
*
First Name
Last Name
INSURANCE COMPANY
*
INSURANCE POLICY #
*
UNDER NAME OF:
*
RELATIONSHIP TO STUDENT:
*
Please List any Medications taking or allergies/physical/mental/dietary conditions that we should be aware of?
*
EMERGENCY CONTACT NAME
*
First Name
Last Name
EMERGENCY CONTACT NUMBER:
*
-
Area Code
Phone Number
OPC MILFORD Staff is allowed to give my student over the counter medications for minor ailments.
*
YES
N0
Please Check box:
*
PARENT/GUARDIAN SIGNATURE
*
Clear
PARENT/GUARDIAN NAME
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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