Louisiana Medical Release Form 1Louisiana Medical Release Form 1
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Office of Orientation – SOUL Camp 2011
Medical Information/Liability Waiver
Name___________________________________ Student ID # _______________
Address___________________________________________________________________
City, State, Zip_____________________________________________________________
Telephone (_____) ________-________ Cell Phone (_____) _______-________

MEDICAL /EMERGENCY INFORMATION:
Parent or Guardian who may be contacted in case of emergency:
Name ___________________________________________________________________________
Address _________________________________________________________________________
City, St. Zip ______________________________________________________________________
Phone (include area code)____________________________________________________________
Family Physician’s Name ___________________________________________________________
Telephone (include area code)________________________________________________________
Health condition (s) requiring