Health Information : Baldwin Park Bilingual SDA Church Baldwin Park CA

Health Information

Supplement to Authorization for Medical Treatment for Minors

Full Legal Name:

Address:

Home Phone:

Date of Birth

Social Security # (Optional)

Child's E-mail

Health Insurance Company

Name of insured:

I.D. & Group Number:

Allergies or Medication being taken:

Please bring a copy of the health insurance card covering the minor.

Name

Address (if different):

Home:

Work:

Cell phone:

Parent's Email

Health Information