MEDICAL & EMERGENCY FORM

Student Information:

Student’s Full Name: Aimie Nicole Luzong Saavedra

Grade & Section: 10 Darwin
Birth Date: October 12, 2006 Gender: Male Female / Home Address: Blk 5, Lot 2,
Camella Glenmont Trails, Brgy. Sauyo, Novaliches, Quezon City

In the event of a medical emergency, medical information and other concerns that should be known about my child
are:

Critical allergies (identify): Allergic to chicken and shrimp

Others (identify):

Persons to contact in case of emergency:

Parent’s Name: Emerson A. Saavedra

Contact Number 1: 09477629342 Contact Number 2:

Parent’s Name: Lilibeth L. Saavedra

Contact Number 1:09674672954 Contact Number 2:

Guardian’s Name: Emerson A. Saavedra

Contact Number 1:09477629342 Contact Number 2: