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I, the undersignd parent or guardian of
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a minor, do hereby authorize the Texas Baha'i School, or its designated representative, agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital ,whether such diagnosis or treament is rendered at the office of the said physician or at said hospital.As the parent/guardian of a minor under the age of 18, I understand that this authorization enables Texas Baha'i School to arrange medical care for my dependant minor in the event I am unavailable.
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I understand that I am responsible for payment of any and all medical expenses incurred on behalf of my dependent minor. This authorization shall remain effective from SEPT 25 to SEPT 27 when my child is attending the Texas Baha'i School.
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Parent/ Guardian Signature
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Emergency Contact Name and Telephone
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Family Physician Name and Telephone
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Medical Insurance Company
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Policy Number
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Additional Emergency Contact( in the event parent cannot be reached)
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Additional Emergency Contact Telephone Number
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List Allergies, Handicaps, Limiting Health Conditions, Medications, Reactions to Medications
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By submitting the form you are signing the medical release, print a copy for yourself
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Must Reply to ALL QUESTIONS even when a no reply is a response.
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