Karl Road Baptist Church

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Person to contact in case of emergency (not parent/guardian)

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CURRENT MEDICAL INFORMATION

Allergies (including food):

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Illnesses/Injuries:

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Special Physical Concerns:

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Medications:

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In case parent/guardian or emergency contact cannot be notified immediately do you authorize a leader to administer any of the following:
TylenolAspirinIbuprofenPepto-Bismol
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Name of Health Insurance Company:

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Name of Person Insured:

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Social Security Number:

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Policy Number:

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Group Number:

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Insurance Company Phone Number:

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Address:

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City:

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State:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth Dakota OhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
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Zip Code:

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Please make sure parent/guardian is present to sign participation agreement form. It is helpful to bring a photocopy of your insurance card.

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