Emergencymedicaltreatmentauthorization sport: fall winter spring male female birthdate: physicaldate: studentname: address: homephone: telephone number where each parent/guardian fatherswork/cell: motherswork/cell:...
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Snowball express letter of consent to attend and travel with someone other than parent or guardian medical power of attorney please print clearly: i, , as parent or guardian of minor child/children: / / , give my authorization for the above...
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Smsa junior sailing camp registration form important ? parents please read!! authorization to consent to treatment of minor i, the undersigned parent or guardian of , a minor, do hereby consent to any emergency x-ray, medical, or surgical...
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Traditional chinese medicine and acupuncture intake form rebecca stephens, dr. tcm, r.ac., b.sc. to assist in providing you with the best possible care, please fill out this form as accurately as you can. all the information provided will be kept...
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Wound care worcester, ma: toll free (855) 880-1091 toll free fax (844) 265-0265 .allcarepluspharmacy.com patient info / prescriber info patient name prescriber name address group/hospital city, state, zip address phone city, state, zip social...
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Pediatric patient intake form patient information name: dob: why are you coming in today? / / sex: m f ssn: contact information home address: city, state, zip code: phone numbers: home cell work please circle the numbers at which we may call you...
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Lincoln basp emergency medical treatment authorization/consent form childs full name: birth date: childs age: childs gender: i, parent or guardian of the child named above, give my permission to lincoln elementary before and after school program...
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Medical treatment authorization player name: birth date: parent/guardian: phones: h: w: c: parent/guardian: phones: h: w: c: emergency contact: emergency phone: physician name: physician phone: medical insurance carrier: known allergies or medical...
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Parental consent form protecting your children while you travel means more than getting a sitter or family relative to watch them. to be absolutely safe, you should provide written authorization for a responsible adult to approve any necessary...
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Medical release authorization & consent form i hereby give my consent to have my child treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the city of porterville arena soccer...
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Parental emergency medical consent form in the event of a medical emergency during the activity/event on / / , i understand that every effort will be made to contact me. in the event medical care must be given for my child before i can be reached,...
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Medical consent and emergency contact form please complete all sections in block capitals sailor details: sailor name: home address: date of birth: age: emergency contacts: name: relationship: home number: work number: mobile number: alternative...
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Medical consent form participant name: parent name: emergency phone #:( )- - emergency info: coaches carry this to all games in case of injury please provide a person?s name other than the parent/guardian to be contacted in case of emergency: name...
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La crosse county human services department 300 north fourth street p.o. box 4002 la crosse, wi 54602-4002 consent for medication dispersal and emergency medical treatment western regional adolescent center i, as the parent /guardian/custodian...
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Gwinnett pediatric partners medical treatment authorization and consent form the following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. this gives authority to a designated adult to...
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