SECTION (II)

Student's name:  ___________________________________________________________

Date of birth:  ________________________________  ID#  ________________________

Home address:  _____________________________________________________________

                           _____________________________________________________________

Home phone #:  __________________________  Cell #:  ___________________________

Parents/Guardians:  __________________________________________________________

                                  __________________________________________________________

Address of Parent/Guardian:  __________________________________________________

                                                  __________________________________________________

High School attended:  ________________________________________________________

City/State of High School:  ____________________________________________________

List any known exposure to radiation, with the exception of routine medical x-rays:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Student's signature:  ________________________________________  Date:  ___________

Parent/Guardian's signature:  _________________________________  Date:  __________