Medical Waiver Student's Name * First Name Last Name Parent Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Phone * (###) ### #### Student Birthdate * Health Insurance Provider * If none type "none" Policy # * If none type "none" Is your student taking any medication? If so, please list: * Medication or food allergies: * Emergency Contact (other than self) * Emergency Contact Phone * (###) ### #### Relationship to Student * Parent/Guardian Signature * Today's Date * MM DD YYYY Thank you!
