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Facts concerning the child s medical history including allergies medications being taken and any physical impairments to which a physician should be alerted Date Signature of Parent/Guardian DO NOT COMPLETE PART II IF YOU COMPLETED PART I PART II REFUSAL TO CONSENT I do not give my consent for emergency medical treatment of my child. EMERGENCY MEDICAL AUTHORIZATION 2016-17 Parish School of Religion Year School Attended Family Name Address / Phone Students enrolled in PSR Purpose - To enable...
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