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Ate Zip Male Female Parent or Legal Guardian s Statement I, the parent or legal guardian of the above named minor, do not wish that life-resuscitating treatment be undertaken in the event of a cardiac or respiratory arrest of the above named minor. Therefore, I direct Emergency Medical Services personnel to withhold life-resuscitating treatment in the event of a cardiac or respiratory arrest of the above named minor. Parent or Legal Guardian s Name (print): Agent s Address: Phone #: S.

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