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First Name:
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Last Name:
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School:
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Gender:
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Address:
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Address 2:
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City:
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Contact Information: |
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Home Phone:
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Parent Name:
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Cell Phone:
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Parent Work Phone(s):
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E-mail:
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Have you attended a Leadership Across America Conference before?
Oh, yes! No, it's my first time.
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If so, where and when?
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Medical Information: |
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Parent/Guardian Name(s)
Parent 1 Name
Parent 2 Name
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Emergency Phone Number
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Emergency Contact Other Than Parent
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Emergency Contact Phone Number
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Insurance Company
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Insurance Policy Number
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Insurance Co. Address
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NOTE: A copy of the FRONT and BACK of the insurance card MUST BE PROVIDED. Please copy and forward prior to January 25 by faxing to 865-531-3683, mailing to LAA, 1435 Queensbridge Drive, Knoxville, Tennessee 37922, or bringing these completed releases with you to Check In on February 5. |
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Are you currently taking medication?
Yes No
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List Medications, if any:
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List allergies, if any:
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Special Health Concerns
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Special Housing Concerns
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