USD 362 ACTIVITIES/FIELD TRIP EMERGENCY INFORMATION TO BE FILLED OUT AND SIGNED BY A PARENT/GUARDIAN AND STUDENT
Student Name (print): _________________________________________________________________
Grade:_________________
Parent/Guardian Name (print):___________________________________________________________________________________________________ Address:___________________________________________________ City__________________________________ Zip_____________________________ Home Phone:______________________________________ Mom Work:________________________________________________
Dad Work:___________________________________________________
Dad Cell:______________________________________________________
EMERGENCY CONTACTS: TWO PERSONS WE CAN CONTACT IN THE EVENT NEITHER PARENT/GUARDIAN CAN BE REACHED:
1) Name (print):____________________________________________________________________ Phone:__________________________________________ 2) Name (print):____________________________________________________________________ Phone:______________________________________ BASIC MEDICAL INFORMATION: Check Yes or No and list date if Yes. Previous Head or Neck Injuries: Yes___ No___ Date___________Major Illnesses: Prior Heat Related Problems: Yes___ No___ Date___________
Medications: Allergies:
Current Insurance Carrier
___________________________________________ Policy Number:_____________________________________ RESPONSIBILITIES OF STUDENT AND PARENT
Participation in extra curricular activities or attendance on a field trip is both an honor and a responsibility. Students earn recognition for their achievements as representatives of their school and its ideals. Good physical conditioning and sound attitudes are integral to participation in Prairie View High School Activities Programs or attendance on a school sponsored field trip. It is a privilege to participate in extra curricular activities or participate in a field trip and this privilege is extended to all, provided that students are willing to assume certain responsibilities. A student participant must be a credit to oneself, the school and the community. PARTICIPATION: I give my permission for my child to participate in organized interscholastic activities including sports, clubs, or other extra curricular activities. I acknowledge that even with the best coaching, use of advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions these injuries can be so severe as to result in total disability, paralysis, quadriplegia, or death. I also acknowledge that participation in any athletics does not guarantee playing time at the varsity level. EQUIPMENT RETURN: I agree to be responsible for the safe return of all athletic and/or activity equipment issued to the above named student by the school. If the equipment can not be returned, I agree to make monetary restitution to the school for said equipment. The school acknowledges that wear and tear will occur on equipment and will not hold said student or parents monetarily responsible for normal wear. EMERGENCY MEDICAL SERVICE: If an emergency service involving medical action or treatment is required, I hereby consent for the above named student to be given medical care by the doctor or hospital selected by the school. Student Signature:________________________________________________________________________________________________________ Parent/Guardian Signature:________________________________________________________________________________________________ Notary Public:_____________________________________________________
I acknowledge that even with the best coaching, use of advanced protective equipment and. strict observance of rules, injuries are still a possibility. On rare ...
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BE IT KNOWN, that, I, the undersigned parent/guardian of the above named student, do hereby give and grant unto any medical doctor, hospital, paramedic or certified school athletic trainer, my consent. and authorization to render such aid, treatment
Page 1 of 1. CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT. Student Name: School: I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs,. movies, or video tapes of the student named above for West
Page 1 of 1. CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT. Student Name: School: I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs,. movies, or video tapes of the student named above for West
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Jan 23, 2017 - Signature of prescriber. Dated. * If the adult consenting to treatment is someone other than a parent or guardian (i.e. an authorized adult acting.
Tom Dougherty. Published online: 10 November 2013. Ã Springer Science+Business Media Dordrecht 2013. Abstract Why is consent revocable? In other words, why must we respect someone's present dissent at the expense of her past consent? This essay argu
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CONT.CAS(C) 584/2014. Mr. Sunil Mittal, Senior Advocate with Mr. Dhruv. Grover and Ms. Seema Seth, Advocates in. CONT.CAS(C) 648/2014. Page 1 of 64 ...