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Consent for Medical Treatment of A Minor Child
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Email
*
Your email
This form is valid for:
*
2022-2023
2022 Fall Teen Academy
2023 Winter Teen Academy
Other:
Child(s) full name
*
Your answer
Birth date
*
MM
/
DD
/
YYYY
Guardian/Parent #1 (first and last name)
*
Your answer
Guardian/Parent #1 Address
*
Your answer
Guardian/Parent #1 Phone number
*
Your answer
Guardian/Parent #2 (first and last name)
Your answer
Guardian/Parent #2 Address
Same as guardian/parent #1
Other:
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Guardian/Parent #2 Phone number
*
Your answer
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