PERMISSION FOR MEDICAL TREATMENT
(parents may not notarize their child's form)
I/We, the undersigned, being the parent, legal next-of-kin, or legal guardian of:
________________________________________________ __________________
(Student's Name) (Birth Date)
hereby authorize emergency medical treatment for this person beginning August 30, 2009 and continuing through June 30, 2010. I/We acknowledge the liability for medical expenses, hospital expenses or other such charges incurred for such services as may be rendered for or on behalf of my/our child as a result of injury or sickness. I/We will assume financial responsibility for the incurred expenses through the insurance company listed below.
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Insurance Company Student's Physican's Name
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Policy Number Home Phone
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Address Student Social Security #
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Parent Cell Phone Parent Cell Phone
Medication and/or food allergies, pertinent medical information, scheduled medications:
________________________________________________________________________
________________________________________________________________________
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Parent's Names (please print)
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Home Address City, State, ZIP
________________________________________________________________________
Home Phone Work Phone 1 Work Phone 2
This document will be taken on all chorus trips and functions. It is the responsibility of the parent to see this properly executed and returned to the chorus room.
Sworn and Subscribed to before me
This ________ Day of ___________ 2009 ______________________________
Parent Signature
__________________________________________________
NOTARY PUBLIC SIGNATURE
State of
My Commission expires: _____________________