Brea RolandYear: 2017-18 School: Los Banos Sport: Soccer, Girls
Student InfoGender:
Female
Grade:
11
Birthdate:
2000-09-24
Student Id:
Address:
2858 Stilt Ln
City:
Los Banos
State:
California
Zip Code:
93635
Home Phone:
2095097551
Student Cell:
2095097551
Student Email:
shawna@thespeck.net
MedicalInsurance Company:
Blue Cross
Insurance #:
XDX5576937
Physician:
Deldin
Physician #:
2095097551
Preferred Hospital:
Los Banos Memorial
Physical Expiration:
11/05/2018
Parents/GuardiansParent/Guardian #1 Name:
Shawna Roland-Sanders
Business #:
2095097551
Mobile #:
2095097551
Email:
shawna@thespeck.net
Parent/Guardian #2 Name:
Ben Roland
Business #:
(209)509-7552
Mobile #:
Email:
Student is living with?
Other Contact Name:
Evan Sanders
Relationship with Student:
step father
Phone Number:
4088211598
Signatures ExecutedTitle
Signature
Category
Statement of Consent
Shawna Roland-Sanders
Parent Signature
ConditionsPainful/Irregular Menstrual Periods
Yes
Student InfoGender:
Female
Grade:
11
Birthdate:
2000-09-24
Student Id:
Address:
2858 Stilt Ln
City:
Los Banos
State:
California
Zip Code:
93635
Home Phone:
2095097551
Student Cell:
2095097551
Student Email:
shawna@thespeck.net
MedicalInsurance Company:
Blue Cross
Insurance #:
XDX5576937
Physician:
Deldin
Physician #:
2095097551
Preferred Hospital:
Los Banos Memorial
Physical Expiration:
11/05/2018
Parents/GuardiansParent/Guardian #1 Name:
Shawna Roland-Sanders
Business #:
2095097551
Mobile #:
2095097551
Email:
shawna@thespeck.net
Parent/Guardian #2 Name:
Ben Roland
Business #:
(209)509-7552
Mobile #:
Email:
Student is living with?
Other Contact Name:
Evan Sanders
Relationship with Student:
step father
Phone Number:
4088211598
Signatures ExecutedTitle
Signature
Category
Statement of Consent
Shawna Roland-Sanders
Parent Signature
ConditionsPainful/Irregular Menstrual Periods
Yes