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Emergency Consent and Proof of Insurance Form
Emergency Consent and Proof of Insurance Form
Student first name
*
enter EXACTLY as you typed it in the main acknowledgement form above
Student last name
*
enter EXACTLY as you typed it in the main acknowledgement form above
Parent/Guardian first name
*
Parent/Guardian last name
*
Home address
Home address line 2
City
State
ZIP
Family primary phone
*
please enter only numbers
0 / 10
Parent/Guardian work phone
please enter only numbers
0 / 10
Emergency contact name
*
Emergency contact phone
*
please enter only numbers
0 / 10
Student's health insurance provider
*
Policy number
*
Family doctor's name
Doctor's phone number
please enter only numbers
0 / 10
AGREEMENT
In consideration of my child’s opportunity to participate in interscholastic activities, I hereby consent to emergency medical treatment, hospitalization, or other medical treatment as may be necessary for the welfare of the child named above, by a physician, qualified nurse, emergency responders, and/or hospital, in the event of injury or illness during all periods of time in which the student is away from his/her legal residence as a member of an interscholastic team or group, and hereby waive on behalf of myself and the above named child any liability of Front Range Christian School, any of its agents or employees arising out of such medical treatment.
I consent to this agreement.
*
Yes
Parent/Guardian signature
*
Please type your full name to represent your signature on this form.
Parent/Guardian email
*
SUBMIT
Please do not fill in this field.
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