Consent for Medical Treatment

Required

BON HOMME SCHOOL DISTRICT

Consent for Medical Treatment

Dear Parents:

Your child is enrolled in an activity or sport which will take him/her away from the school at some time during the year. If your child should become injured or ill while away, it is necessary for us to have your permission to assure that we can get him/her needed medical treatment.

Please sign and return this form to the Principal’s Office of your child’s school as soon as possible. This form will accompany your child on all out-of-town trips.

Sincerely,

Brad Peters

Superintendent of Schools

CONSENT FOR MEDICAL TREATMENT

Student Graderequired

(i.e. 10)

I am (choose one)required

Mother

Father

Legal Guardian

Of Student Name:required

who participates in extra-curricular activities for Bon Homme School District #04-2.

I hereby consent to any medical services that may be required while said child is under the supervision of an employee of Bon Homme School District #04-2 while at school sponsored activities. I hereby appoint said employee to act on my behalf in securing necessary medical services from any duly licensed physician or osteopath.

Namerequired

First Name

Last Name

Daterequired

Must contain a date in M/D/YYYY format

Home Phone:

Mom's Cell Phone:

Mom's Work Phone:

Dad's Cell Phone:

Dad's Work Phone:

STUDENT CONSENT

I, Student Name:required

have read the above Consent Form signed by my (choose one) and join with him/her in consent.required