Should it be necessary for me to have medical treatment while participating in this trip, I hereby give the School District personnel permission to use their judgment in obtaining medical service for me and I give permission to the physician selected by the School District personnel to render medical treatment deemed necessary and appropriate by the Physician. I understand that the School District has no insurance covering such medical or hospital costs incurred for me and, therefore, any cost incurred for such treatment shall be my sole responsibility.
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______Please check here if special instructions regarding medical treatment are on file in the school. Student's Name ________________________Student's Signature__________________________ PLEASE PRINT Student's Address________________________Student's Home Telephone___________________ Student's Business Telephone_______________ Student's Emergency Phone________________ |