Long valley baseball club 2011 travel baseball medical treatment authorization form as a parent and/or guardian of , a minor, i hereby authorize the treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in...
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Iowa 4-h medical information/release form (non 4-h club members - youth) 2012-2013 keep original in county office. participant information participant's name permanent address city, state, zip medical emergency contact information person to...
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4v4 soccer tournament/league player medical release form each player must fill out a medical release form before participating in the 2010 spring games. please fill out all necessary information and send to your team representative. team...
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5600pmbmp0385 instructions rev. 11/2014 commonwealth of pennsylvania department of environmental protection bureau of mining programs instructions for completing renewal application coal mining activity permit general information 1. this...
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Adult medical release form date: print name: parish: address: city: state: zip code: home phone number: ( ) work phone number: ( ) physician s name: phone # ( ) date of birth: date of last tetanus shot: please list all medical...
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Acknowledgement and assumption of risk and medical consent formthe undersigned, being of legal age or signing in conjunction with a parent or legalguardian if not of legal age, hereby gives permission to randolph college and theinsert name of camp...
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Spectrum psychological associates, inc. consent to treat i, (print the patient s full name on the line) authorize providers of the spectrum psychological associates, inc. (spectrum) to treat me for my health, wellness and routine care management....
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Last name first name adult information and waiver form all magdalena ecke family ymca members and participants must have a completed form on file. please print last name ? female first name ? male birth date e-mail address city home phone zip work...
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Archdiocese of galveston-houston adult medical release form i, , do hereby release, hold harmless and discharge the archdiocese of galveston-houston, its staff and volunteers from any and all liability, claim, loss, damage, cost or expense arising...
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Snow camp 2013 university of california division of agriculture and natural resources 4-h youth development program adult medical release form this medical release form is authorized for all 4-h youth development meetings and activities during the...
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University of california division of agriculture and natural resources 4-h youth development program adult medical release form this medical release form is authorized for all 4-h youth development meetings and activities during the dates...
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This formis to be carried all sanctioned to competitions practices. & s s/dmyfl. player 2013.2014 volleyball usavyouth junior & form medical release this muat be compleiad- logibly- and sign d in all arbasby both the pley r and his/her parentor...
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Temporary child guardian consent form the parent(s)/ guardian(s) full name(s) and surname(s): and address: contact phone number(s) and details: the child(ren) full name(s) and date of birth: the temporary guardian(s) full name(s) and surname(s):...
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Ball state university school of nursing medical release form name date diagnosis date hospitalized: from to surgery date date released to return to class and/or clinical recommendations: may return to class only may return to class and clincial...
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The forms listed below must be submitted and on file in our business office before your child can begin classes. forms needed for a child to begin school enrollment application form enrollment agreement child enrollment information nutrition...
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