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Get FL SB77501 2002

School District of Hillsborough County MEDICAL RELEASE FORM This form is used to record parental permission for medical and surgical treatment in case medical concerns arise during a field trip. We the undersigned as the parents and legal guardians of Print Student s Name hereby consent to any and all medical and surgical treatments including anesthesia and operations which may be deemed advisable by any qualified physician selected by agents or officials of the Hillsborough County School Board. The intention thereof is to grant authority to administer and to perform all and singularly any examinations treatments anesthetic operations and diagnostic procedures which may now or during the course of the patient s care be deemed advisable or necessary by any qualified physician* Witness of our consent and agreement to the matters stated above we have subscribed our signatures below. Parent/Guardian Signature Date STATE OF FLORIDA COUNTY OF SUBSCRIBED and sworn to before me a Notary Public this day of. Notary Medical Insurance Company Policy Student s Address Phone Date of Birth Father Home Phone Business Business Phone Mother Family Physician s Name Address City State Allergies or Special Conditions NOTE In the event of an emergency medical situation even with the form the chaperone will attempt first to contact the student s parent/guardian* Disposition Copy to office Original is retained by teacher and taken on the field trip* Form SB77501 revised 08/16/02 Page 17. The intention thereof is to grant authority to administer and to perform all and singularly any examinations treatments anesthetic operations and diagnostic procedures which may now or during the course of the patient s care be deemed advisable or necessary by any qualified physician* Witness of our consent and agreement to the matters stated above we have subscribed our signatures below. Parent/Guardian Signature Date STATE OF FLORIDA COUNTY OF SUBSCRIBED and sworn to before me a Notary Public this day of. Parent/Guardian Signature Date STATE OF FLORIDA COUNTY OF SUBSCRIBED and sworn to before me a Notary Public this day of. Notary Medical Insurance Company Policy Student s Address Phone Date of Birth Father Home Phone Business Business Phone Mother Family Physician s Name Address City State Allergies or Special Conditions NOTE In the event of an emergency medical situation even with the form the chaperone will attempt first to contact the student s parent/guardian* Disposition Copy to office Original is retained by teacher and taken on the field trip* Form SB77501 revised 08/16/02 Page 17. The intention thereof is to grant authority to administer and to perform all and singularly any examinations treatments anesthetic operations and diagnostic procedures which may now or during the course of the patient s care be deemed advisable or necessary by any qualified physician* Witness of our consent and agreement to the matters stated above we have subscribed our signatures below. Parent/Guardian Signature Date STATE OF FLORIDA COUNTY OF SUBSCRIBED and sworn to before me a Notary Public this day of. Notary Medical Insurance Company Policy Student s Address Phone Date of Birth Father Home Phone Business Business Phone Mother Family Physician s Name Address City State Allergies or Special Conditions NOTE In the event of an emergency medical situation even with the form the chaperone will attempt first to contact the student s parent/guardian* Disposition Copy to office Original is retained by teacher and taken on the field trip* Form SB77501 revised 08/16/02 Page 17. .

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