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Medical Info Form

Contact/Medical Info


For numerous reasons I need to know the CURRENT contact and medical information about your child. Please fill out the following form and send it back to me as soon as possible!! Also, if any of this should change during the year please send the updated information. Thank you for your cooperation. J


Students Name:


Parents Name:


Home Address:


City: ________________    State: KY       Zip Code:______________


Phone Number (the one you want your child to learn)



Emergency Contact



Meds and allergy/ any other




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