* 1. Please provide the following information:

* 2. Does your child have any allergies?

* 3. If "yes," please list allegies:

* 4. Does your child have medications, of any type, with her him?

* 5. If "yes," please list the medication(s) your child has.

* 6. Is there any other physical or emotional condition of which we need to be aware? Please explain.

* 7. In the event of an emergency, I give authority to the accompanying adults to authorize treatment. I understand that an attempt to notify me will be made before any treatment is authorized. I understand that providing my name and parishioner number here constitutes an electronic signature.

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