Medical Information Form
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Student Information
Last Name:
First Name:
Middle Name:
Siblings at Pilgrim:
Address:
Home #:
Students Cell#:
DOB:
Grade 2013-14 School Year
Student’s email:
Who is the student’s legal guardian/s?
Who does the student live with?
Primary Contact: Parent/Guardian Information
Last Name:
First Name:
Street Address (if different than the student):
Home #:
Cell#:
Accept texts?
[
] N
[
] Y
Employer:
Work #
Email:
Secondary Contact: Parent/Guardian Information
Last Name:
First Name:
Street Address: (if different than the student):
City
State
Zip Code
Home #:
Cell#:
Accept texts?
[
] N
[
] Y
Employer
Work #
Email:
Is this person authorized to pick up the child if they
[
] No
[
] Yes
become ill during school hours?
Emergency Contact Information
Last Name:
First Name:
Home Phone #
Cell #:
Work #
Is this person authorized to pick up the child if they
[
] No
[
] Yes
become ill during school hours?
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