Mount Vernon Nazarene University: Life Changing
Medical Form

Student's Name
Parent/Guardian Name
Home Phone
Cell Phone
Any medication the child might
need during the camp hours?
Any allergies?
Name of primary doctor?
Name of dentist?

In the event that efforts to reach me by phone are not successful, I give permission for my child to be treated in an emergency by the doctor and/or Knox Community Hospital.

 
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