Maria PasillasYear: 2017-18 School: Los Banos Sport: Soccer, Girls
Student InfoGender:
Female
Grade:
11
Birthdate:
2000-08-23
Student Id:
5511697
Address:
1749 Fir Dr
City:
los banos
State:
California
Zip Code:
93635
Home Phone:
(831)419-3068
Student Cell:
(209)752-5461
Student Email:
mariapasillaslupita1313@gmail.com
MedicalInsurance Company:
State of CA. medical
Insurance #:
92421877E23329
Physician:
N/A
Physician #:
N/A
Preferred Hospital:
Los Banos
Physical Expiration:
10/17/2018
Parents/GuardiansParent/Guardian #1 Name:
Paula Lopez
Business #:
(831)419-3068
Mobile #:
(831)419-3068
Email:
mariapasillaslupita1313@gmail.com
Parent/Guardian #2 Name:
Ladislao Pasillas
Business #:
(831)761-1324
Mobile #:
(831)212-0418
Email:
LADISPASILLAS@GMAIL.COM
Student is living with?
mom dad
Other Contact Name:
Guadalupe Villagomez
Relationship with Student:
neighbor
Phone Number:
(408)807-1095
Signatures ExecutedTitle
Signature
Category
Statement of Consent
Paula Lopez
Parent Signature
ConditionsConcussion or Head Injury
Yes: 01-30-17
Heat illness, treated or hospitalized
Yes: 01-30-17
Family history of diabetes
Yes
Wears contact lenses/glasses
Yes: Only needed to see far away
Broken Bones
Yes: Fractured jaw from car accident 5 years ago
Student InfoGender:
Female
Grade:
11
Birthdate:
2000-08-23
Student Id:
5511697
Address:
1749 Fir Dr
City:
los banos
State:
California
Zip Code:
93635
Home Phone:
(831)419-3068
Student Cell:
(209)752-5461
Student Email:
mariapasillaslupita1313@gmail.com
MedicalInsurance Company:
State of CA. medical
Insurance #:
92421877E23329
Physician:
N/A
Physician #:
N/A
Preferred Hospital:
Los Banos
Physical Expiration:
10/17/2018
Parents/GuardiansParent/Guardian #1 Name:
Paula Lopez
Business #:
(831)419-3068
Mobile #:
(831)419-3068
Email:
mariapasillaslupita1313@gmail.com
Parent/Guardian #2 Name:
Ladislao Pasillas
Business #:
(831)761-1324
Mobile #:
(831)212-0418
Email:
LADISPASILLAS@GMAIL.COM
Student is living with?
mom dad
Other Contact Name:
Guadalupe Villagomez
Relationship with Student:
neighbor
Phone Number:
(408)807-1095
Signatures ExecutedTitle
Signature
Category
Statement of Consent
Paula Lopez
Parent Signature
ConditionsConcussion or Head Injury
Yes: 01-30-17
Heat illness, treated or hospitalized
Yes: 01-30-17
Family history of diabetes
Yes
Wears contact lenses/glasses
Yes: Only needed to see far away
Broken Bones
Yes: Fractured jaw from car accident 5 years ago