ࡱ> *,+q` bjbjqPqP *::         $< hz+  +  @ : : :    :  : :    0{SK F  V 0    , 4 : B N p + + 0  Raider Rugby Authorization For Emergency Medical Transport And / Or Treatment I_______________________________ the undersigned parent or guardian of the minor child ____________________________, hereby authorize and appoint the coach and / or administrator of RAIDER HIGH SCHOOL RUGBY FOOTBALL CLUB, to request and authorize emergency medical transport and / or treatment on behalf of my child. HOWEVER, this authorization shall be effective ONLY in the event of an emergency, and ONLY if appropriate paramedical, medical and / or hospital personnel have been unable, after reasonable efforts, to contact the undersigned (or one of the persons designated below) so as to obtain authorization for emergency medical transport and / or treatment. I direct and request that efforts be made to contact the following persons in the event of an emergency involving my child: TELEPHONE NUMBERS NAME HOME WORK OTHER RELATION _____________ ________ _________ _________ __________ _____________ ________ _________ _________ __________ _____________ ________ _________ _________ __________ _______________________ ____________________ ______________ PARENT SIGNATURE PRINT NAME DATE SIGNED TO BE COMPLETED BY PARENT: Does your child have any allergies (i.e to drugs, bee stings, etc.)? Yes___ No___ If yes, please describe allergies:________________________________________ Is your child currently receiving any medications? Yes___ No___ If yes, please describe medications:________________________________________________ Are you aware of any medical or other condition (s) which would prohibit your child from participating in contact sports? If so, please describe: Medical Insurance Carrier or HMO: ______________________________ Name of Primary Insured: ______________________________________ Group I.D. # :__________________________________________________ Policy #: ______________________________________________________  On   +l h-C5 h-CCJh-C h-C5CJh-C5>*CJ h-C5CJ h-CCJ h-CCJ$NOe f   K L M 0 { |  &dP $^`a$$a$+l &d P (/ =!"#$% 8@8 Normal_HmH sH tH >@> Heading 1$@& 5>*CJ<@< Heading 2$@&5CJ<@< Heading 3$@&5CJDAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List 4>@4 Title$a$5CJ46B@6 Body Text5CJ6P@6 Body Text 2CJNOefKLM0{|+lI0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0  o V*urn:schemas-microsoft-com:office:smarttagsplacehttp://www.5iantlavalamp.com/ 37QS6933333+(