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Submit by Emailing Format. Andrew's School232 Durham Road Madison, CT 06443 (203)2451308 Fax (203)2452601 Judy standrewsschoolct. Emergency Medical Care & Consent Form STUDENT Name Date of BirthAddressPhone

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Next, provide your insurance information, including policy number and contact details of the insurance provider.

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Enter the details of your emergency contact person, including their name, relationship, and contact number.

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Explain the reason for seeking emergency medical care in the designated section.

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Provide a chronological account of symptoms or incident leading to the need for emergency care.

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