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PARENT/GUARDIAN; Youmustcfreckline 1 or line2 to lndcab actiondesiredin the enentof an as;k&nt or emergency. 1.-

In fie e\rentof an accidentor ofter emergercy,when a parcnUgnradianis urnrraitable,I herebyaufiorize a representativeol the schoolto makesuch anangemelF ?s he/sheconsidersneceqsaryfor my child to rgcelve iredlcal or trosgtatcare, tndudingnecessarry fansPortaffon..Under suctrclrcurnstances,t turttier authorizethe t'hyoiciannamedbeloi,vto underiake slrch care and tr€atmentol my chlldas.he/sheconsidersnec€ssary. In ths ewnt satd'phlrsHanls not availableat eny tims, I authorizesuchcaro and treatmentto b perlcrmedby any licensridphysiclanor surgeon. THEUI'IDERSIGTIED HERESYAGREESTO EEARALL COSTSINCURRED A$ A REST'LTOF THEFOREGOITIG: Physi<*n'sf{ame

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| do not choosetre above s.tatenrsntand desirethe followirlgaction:

PARENT/GUARDIAI{: Flease xndicate any physicaumedlcal problems lo be consldered regarding thls lrlp or any neoessary ennergency trcat!fient (medicatlons, allerglee, condltions, eto.l

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