Child Medical Consent

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Contact Information
Your Name*
First Last
Email*
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Parent of Legal Guardian Information
Parent of Legal Guardian Name*
First Last
Guardian's Relationship to Child*
- Parent
- Legal Guardian
Parent of Legal Guardian Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Temporary Caregiver Information
Caregiver's Name*
Caregiver's Address*
Street Address Address Line 2 City State ZIP Code
Caregiver's Relationship to Child*
- An educational institution in which the child is enrolled.
- An adult who has the care and control of the child.

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