Lizbeth EspinozaYear: 2017-18 School: Los Banos Sport: Soccer, Girls
Student InfoGender:
Female
Grade:
10
Birthdate:
2002-07-07
Student Id:
61589
Address:
1114 oatgrass way
City:
Los banos
State:
CA
Zip Code:
93635
Home Phone:
(209)270-0439
Student Cell:
(209)270-0439
Student Email:
Lizbethespinoza295@gmail.com
MedicalInsurance Company:
Central California allian
Insurance #:
90974498D
Physician:
N/A
Physician #:
N/A
Preferred Hospital:
Nearest Hospital
Physical Expiration:
08/17/2018
Parents/GuardiansParent/Guardian #1 Name:
Maria Aguilar
Business #:
(209)675-6915
Mobile #:
(209)675-6915
Email:
Lizbethespinoza295@gmail.com
Parent/Guardian #2 Name:
Rigoberto Espinoza
Business #:
1 (209) 675-807
Mobile #:
1 (209) 675-807
Email:
Lizbethespinoza295@gmail.com
Student is living with?
Mom and dad
Other Contact Name:
Oliva
Relationship with Student:
Aunt
Phone Number:
(408) 401-193
Signatures ExecutedTitle
Signature
Category
Statement of Consent
MA
Parent Signature
Student InfoGender:
Female
Grade:
10
Birthdate:
2002-07-07
Student Id:
61589
Address:
1114 oatgrass way
City:
Los banos
State:
CA
Zip Code:
93635
Home Phone:
(209)270-0439
Student Cell:
(209)270-0439
Student Email:
Lizbethespinoza295@gmail.com
MedicalInsurance Company:
Central California allian
Insurance #:
90974498D
Physician:
N/A
Physician #:
N/A
Preferred Hospital:
Nearest Hospital
Physical Expiration:
08/17/2018
Parents/GuardiansParent/Guardian #1 Name:
Maria Aguilar
Business #:
(209)675-6915
Mobile #:
(209)675-6915
Email:
Lizbethespinoza295@gmail.com
Parent/Guardian #2 Name:
Rigoberto Espinoza
Business #:
1 (209) 675-807
Mobile #:
1 (209) 675-807
Email:
Lizbethespinoza295@gmail.com
Student is living with?
Mom and dad
Other Contact Name:
Oliva
Relationship with Student:
Aunt
Phone Number:
(408) 401-193
Signatures ExecutedTitle
Signature
Category
Statement of Consent
MA
Parent Signature