VPC Minor Medical Release

Minor Name(Required)

First Last

Minor Email (if applicable)

Minor Date of Birth(Required)

Minor Gender(Required)

Male

Female

Year of High School Graduation(Required)

Which school do you attend?(Required)

What size t-shirt do you wear?(Required)

Minor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Name(Required)

First Last

Parent Guardian Phone(Required)

Parent Guardian Email(Required)

Second Parent/Guardian Name

First Last

Second Parent/Guardian Phone

Second Parent/Guardian Email

Insurance Company(Required)

Please write n/a if uninsured.

Insurance Policy Number(Required)

Please write n/a if unisured.

Non Parent Emergency Contact Name(Required)

First Last

Non Parent Emergency Contact Phone(Required)

Non Parent Emergency Contact Relationship to Student(Required)

Medical Alerts: OTC and RX, dosage schedule

Medical Alerts: Allergies(Required)

By my signature, the parent and/or the guardian of the above minor, I grant my permission for him/her to participate fully in activities or trips sponsored by Vienna Presbyterian Church.

Signature of Parent or Legal Guardian(Required)

Today's Date(Required)

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OUR LOCATION

124 Park St, NE
Vienna, VA 22180
703.938.9050

VPC Minor Medical Release

OUR LOCATION

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