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Medical Information Form (Form #1)
To be completed by a parent/guardian AND the participant.
1
Student Information
2
Parent & Emergency Contacts
3
Medical Information
4
Agreement and Waivers
▶
1
Student Information
2
Parent & Emergency Contacts
3
Medical Information
4
Agreement and Waivers
Today's Date
MM
/
DD
/
YYYY
Please Note: This form uses ReCaptcha (TM) technology to keep your information safe and strictly confidential.
Summer/Acceptance Email Address:
*
Please confirm the registration email address that will be checked regularly and will not be changed until after August 2015.
Confirm Email
Program Location
*
Select Location
Western
Gonzaga
Central
PLU
STUDENT INFORMATION
Student Name
*
First
Last
Middle Intial
Date of Birth
*
MM
/
DD
/
YYYY
Student Email
Home Phone Number
*
###
-
###
-
####
Student Cell Phone Number
###
-
###
-
####
High School
Grade - 2014/15 School Year
*
Freshman
Sophomore
Junior
Senior
Ethnicity (for statistical purposes only):
African American / Black
Asian
Pacific Islander
Caucasian / White
American Indian
Native Alaskan/Aleutian
Hispanic / Latino
Other
1
/
4
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