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Pep Squad Member Information
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Email
*
Record my email address with my response
Last Name
*
Your answer
Middle Name
*
Your answer
First Name
*
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mother's Name
Your answer
Phone Number
Your answer
Father's Name
Your answer
Phone Number
Your answer
Parent Email
Your answer
Name of person student lives with.
*
Your answer
First person to call
*
Option 1
Other emergency contact name
Your answer
Relationship
Your answer
Emergency Contact Phone Number
*
Your answer
Allergies
*
Your answer
Medical Problems/Conditions
*
Your answer
Medications
*
Your answer
Family Doctor
*
Your answer
Family Doctor Phone Number
*
Your answer
Insurance Company
*
Your answer
Policy Number
*
Your answer
I have printed a copy of my insurance card front and back and turned in to Good Hope.
*
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No
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