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CENTRAL TEXAS CHRISTIAN SCHOOL Emergency Medical Release Form
In case of accident, illness, or other emergency, I/we request that I/we be contacted. If I/we cannot be reached after conscientious effort, I/we give permission for a CTCS or SLU sponsor to call paramedics or attempt to contact listed physician or dentist first. If a life-threatening emergency exists, I/we give permission for a CTCS or SLU sponsor to call paramedics immediately and then contact me/us as soon as possible thereafter.
I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical treatment, and hospital care which, in the best judgment of a licensed physician or dentist, is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for emergency medical transportation.
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SLU Participant Name (First, Middle, & Last): *
Student Email *
Date of Birth:
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Gender: *
Required
Physician: *
Physician's Phone: *
Dentist: *
Dentist's Phone: *
Health Insurance Carrier: *
Policy Number: *
Insured’s Name: *
Relationship: *
In case of emergency, phone# where you can be reached: *
Alternate Number: *
Allergies (including reactions to medications) (Please type N/A if applicable): *
Are there any physical or medical conditions we should know about not already stated? (Please type N/A if applicable) *
Digital Signature *
Please select date of digital signature: *
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