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MCDA MEDICAL RELEASE FORM

MCDA Medical Release Form

Online

Team Name

Program/Gym Name

Participant Name

Participant Street Address

City

State

Zip Code

Parent or Guardian's Cell Phone

Emergency Contact Name

Emergency Cell Phone

Medical Insurance Company

Medical Insurance Policy number

Today's Date

Your Signature

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contact

LOCATION

PO Box 50 | Bethalto, IL 62010

PHONE

Kim 618-530-7948

Kristi 629-333-6398

EMAIL

kim@midwestcheeranddance.com

kristi@midwestcheeranddance.com

DUNS

051300461

CAGE CODE

8P0X3

Quick Registration

Forms & Waivers

MCDA Medical Release Form

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