27 Completed by Parent/Guardian Insurance and Emergency Information Form ~ Completed by Parent/Guardian Personal Data Student's Name: Mayer} Rene BirthDate: ]. 3\,00 lel $C 245 © Murrells Inte 1 Students Home Adtrese: 8% SULCYPCESS KY Home Phone: US, 541,23 ¢S SetoolNane: St SAMS ugh 6s | School Counselor, Uv . Wood Address: Phone: Tisurance Coverage Yes{S Family Schgol Employer Liability and/or Bonding Yes (VA)Tort Liability Workers’ Compensation Ye(N/A Workers “Compensation Health/Accident Yes Student Insurance Name of Health/Accident Insurance Company: Insured: Policy #: (Note: Please identify ‘who is providing coverage by placing an (X) in the appropriate space.) ‘Student Medical Information List medical information about the student that would be helpful in case of emergency. - Allergic to medications? () Yes No Ifyes, what medications? List any allergies or other medical problems of the student: AU A Family Information ' | Parent/Guardian Name: (We\s Ca RSE. Work Phone: 4X3. 941. 2367 Employer Name/Adaress: SE\F-- ermplO-4fed / 3535 Cactus MB 24s44 Parent/Guardian Name: Work Phone: 443,541. LS UT Employer Name/Address: Sel employed ie ParentGuardian Home Address: 2U. crpress Wu. Murrells | Home Phone: 443.54 1. L4SUS~ Emergency Contact: Phone: P29 Y4 RewOt BY3,4UT 1,03 31 I consent for my child to receive emergency medical treatment in case of injury or illness. The information proyided is ageprate to the best of my knowledge. ZN aa stare Date ; ). La \W Parent’s/Guardian’s Signature Date Horrf County Schools does not discriminate on the basis of race, religion, color, nlek $624 tH