PERMISSION SLIP FOR MEDICAL EMERGENCY
This is to certify that
____________________________ (student) has our permission to participate in all
Large Group and/or Individual Speech contests (both Districts and State) during
the 2011-2012 school year.
We realize that there are risks involved
in any activity/trip. We do hereby
agree to assume these risks and we do hereby release and hold harmless the Red
Oak Community School District, including faculty and staff sponsor(s) of any
and all liability which may arise as a result of our student’s participation in
the activity/trip.
We also empower Mrs. Laura Horn to
authorize emergency medical treatment for the above-named student and we agree
to accept responsibility for the cost of any medication/medical
services/x-rays/medical transportation prescribed by a licensed physician or
required as necessary to be administered or arranged under sponsor(s)
direction.
Our medical insurance program and number
is:
_______________________________________/
__________________________
Dated:__________________________
____________________________________________
Parent/Guardian Signature
Our home phone number is: _________________________
Our work phone number(s) is/are:
___________________________
Our cell number(s) is/are: ________________________
