MIME-Version: 1.0 Content-Location: file:///C:/E674468D/EXTRACURRICULARFORM.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" EXTRA-CURRICULAR ACTIVITY

EXTRA-CURRICULAR ACTIVITY

EMERGENCY TREATMENT FORM

 

The Hume R-8 School District has my permission to seek treatment for my student at the nearest medical facility if a medical situa= tion warrants. I further authorize the attending representat= ive(Coach, Sponsor, Administrator) of the Hume R-8 School District to make decisions in place of myself for the treatment of my child if I am unable to be reached = by telephone.

 

 

_______________________________________      ___________= ___________________

Student’s Full Name(P= rint)        &= nbsp;           &nbs= p;            &= nbsp;          Parent&#= 8217;s Full Name(Print)

 

_______________________            &n= bsp;            = ;             <= /span>______________________________

Date   =             &nb= sp;            =             &nb= sp;            =             &nb= sp;           Pare= nt’s Signature

 

 

Home Phone#  = ;            &n= bsp;           Work Phone#      &= nbsp;        Cell Phone#

 

Other Phone #’s

 

 

   &nbs= p;            &= nbsp;           &nbs= p;               &= nbsp;   Insurance Information

 

_____________________________            =             &nb= sp; ___________________________

Insurance Provider&nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;     Name on Card

 

_____________________________            =             &nb= sp; ___________________________

Group Name  =             &nb= sp;            =             &nb= sp;            =             G= roup Number

 

 

Insurance Provider Address

 

_____________________________            =             &nb= sp; ____________________________

Insurance Company Phone #        &= nbsp;           &nbs= p;            &= nbsp;      Student D.O.B.

 

Student’s SSN