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  LBHS JV Girls Soccer Team
​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
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