Massachusetts Medical Release Form 2
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MIT Campus Preview Weekend 2013: Medical Release Form
THIS FORM MUST BE COMPLETED AND RETURNED BY MARCH 28, 2013
All students attending Campus Preview Weekend must complete and return this form via fax.
Please fax your completed form to 617-687-9184 no later than March 28, 2013.
*Parents must complete this form for students under the age of 18.*
Student’s Name:
FAMILY/LAST NAME

FIRST/GIVEN NAME

MIDDLE NAME

Home Address:
STREET
CITY

STATE

Cell Phone: __________________________

ZIP

Birth Date: _____________________
MONTH/DAY/YEAR

Father/Guardian:___________________________

Mother/Guardian: ___________________________

FULL NAME

FULL NAME

Day/Cellphone:_____________________________

Day/Cellphone: ___________________________

(AREA CODE)

(AREA CODE)

Evening Phone:_____________________________

Evening Phone: ___________________________

(AREA CODE)

(AREA CODE)

Name and phone of person with whom student resides:______________________________________________
(if different fro