Student name (please print) last first (id #) centerville city schools emergency medical authorization form (ohio revised code 3313.712) date of birth home phone school address school year grade city zip purpose: to enable parents and guardians to...
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Ball page kwy ester z lindbergh g ai cr ster new ballas manche kingsh ig et hway bl vd d hu mackl in sc rk p oakland craig page service dr t pa manch va n de ve n te r fe e fe e t forest park fore s barnesjewish hospital campus taylor et page etz...
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Emergency medical authorization form child s name: father s name: mother s name: address: city/st/zip: home phone: cell/other: consent: please complete part 1 or 2: this is to enable parents /guardians to authorize the provision of emergency...
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Emergency medical authorization form player name: dob: phone: home address: zip: physician: phone: preferred hospital: known allergies: in case of emergency, we will attempt to contact a parent at home or at work. if we cannot be reached, attempt...
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The bridgeport school district emergency medical authorization form student i.d. date of birth grade student name address city state zip telephone ( ) the purpose of this form: to enable parents/guardians to authorize provision of emergency...
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Emergency medical authorization form purpose: to provide vital contact information and to enable the parents or guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, in the...
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Findlay city schools emergency medical authorization form (ohio revised code 3313.712) student name school building: school year: 2015 - 2016 address grade parent email: ? ? ? parents: married divorced separated if divorced/separated/other, who is...
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Hipaa medical authorization form authorization for release of medical records and reports full name: date of birth: social security no: i hereby authorize all health care providers, physicians, hospitals, clinics and institutions, medical...
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Banner id (office use only) medical authorization form note: student may not participate in continuing education programs until this form has been received. this form does not require a physician's signature. brown university, box t providence,...
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Youth programsmedication authorization(only one medicine per form)the above named child required medication, which must be taken during activity hours.failure to receive this medicine will result in his/her being unable to participate in...
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Town of mt. pleasant recreation & parks 1 town hall plaza valhalla, ny 10595 914-742-2310 fax: 914-769-1070 medical authorization form- permission for self-medication administration new york state board of health regulations require that campers...
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S&s consolidated independent school district s&s consolidated independent school district p.o. box 837 ? sadler, texas 76264 ? office: (903) 564-6051 ? fax: (903) 564-3492 ? .sscisd.net medical authorization form i/we, being the parent(s) or legal...
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M edical e mergency important information if your child(ren) needs medical, dental, hospital or other health services, you as a parent must give permission in most cases. it s the law. the information contained in this document complies with...
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Release, waiver and medical authorization gustavus adolphus college off-campus programs this is a release read it very carefully. id # name: date program or course semester 1 semester ii full year january term i, (student s name) will be...
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Web of life field (wolf) school medication authorization child 's name (m f) birthdate in accordance with california education code 49423, in order for your child to receive over-the-counter or prescription medication while attending the web of...
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