MVCC Permission Slip

Your name *

Email address *

Participant Information

Student Full Name *

Birthdate *

Phone Number *

Address *

Emergency Contact

Name *

Phone # *

Relationship to the participant *

Insurance Information

Does the participant have health insurance? *

Yes

Name of primary care physician *

Phone # of primary care physician *

Please list any physical problems, limitations, allergies, or significant medical history which may be needed in case of an emergency. Also list any medications which your son/daughter is currently using. *

Parent/Guardian Signature

I hereby give my permission for my son/daughter to attend activities with MVCC. I also give permission for my son/daughter to receive any medical attention that may be deemed necessary. Please type your name here to indicate consent. *

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