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Medical Emergency Information Form

In the event of illness or injury occurring to my student while on this travel/activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental, surgical), anesthesia or diagnostic procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical office staff furnishing such services. 


I further acknowledge that I am financially responsible for any medical, dental, ambulance or other health care expenses or transportation of my child home, which might occur as a result of such illness or injury. I also acknowledge that I may obtain accident insurance through the school if I do not currently have family medical insurance. 


I understand that, in the event of other that minor illness or injury, responsible effort will be made to contact me. 


Emergency Contacts, if Parent/Guardian is unable to be reached:

Do you authorize a certified district employee or Principal's designee to give your child acetaminophen or ibuprofen?
Yes
No
Additional Info
Is your child on daily medication?
No
Yes

*If yes, complete the consent below*

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