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  LBHS JV Girls Soccer Team
​chloe emersonYear: 2017-18 School: Los Banos Sport: Soccer, Girls

Student InfoGender:
Female

Grade:
12

Birthdate:
2000-02-02

Student Id:

Address:
18263 ortigalita rd

City:
Los Banos

State:
CA

Zip Code:
93635

Home Phone:
(209)704-3644

Student Cell:
(209)704-3644

Student Email:
chloeemerson6@gmail.com
MedicalInsurance Company:
kaiser 

Insurance #:
10963177

Physician:
catherine snively

Physician #:
(408)848-4095

Preferred Hospital:
nearest hospital

Physical Expiration:
08/02/2018
Parents/GuardiansParent/Guardian #1 Name:
jenny emerson

Business #:
(209)704-0098

Mobile #:
(209)704-0098

Email:
jennypoto@hotmail.com

Parent/Guardian #2 Name:
scott emerson

Business #:
(209)704-0097

Mobile #:
(209)704-0097

Email:
compeye@pacbell.net

Student is living with?
both parents

Other Contact Name:
karen raymond 

Relationship with Student:
grandmother 

Phone Number:
(904)264-9878 
Signatures ExecutedTitle
Signature
Category

Statement of Consent
jenny emerson
Parent Signature
Copyright © 2017
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