2019-2020 PSR Medical Information Form

Fill out ONE form per family.

Child 1

Child 2

Child 3

Child 4

Child 5

  • I authorize emergency treatment to be administered to the above named child/children.
  • I understand that every attempt will be made to reach me, but if the severity of the injury indicated the necessity, the emergency response system may be called.

TERMS OF ACCEPTANCE and SIGNATURE

I acknowledge that the information provided in this form is correct.

 
I understand that checking this box constitutes a legal signature.


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