2025 Life Safety Registration Form and Waiver

Student Full Legal Name (required)

Home address (required)

Date of birth (required)

Last grade completed (required)

Shirt size (required)

Parent/Guardian name (required)

Parent Home address (required)

Parent phone number (required)

Zip Code (required)

Emgerency Contact-Name/Relationship/Phone number (required)

Medical Insurance/Health Plan (required)

Policy ID# (required)

Primary Physician Name/location/phone number (required)

Medication Allergies, please list (required)

Food Allergies, please list (required)

EpiPen Required (required)

yes

no

Current Medical Conditions Requiring Treatment (required)

Other Significant Medical Information (required)

I DO HEREBY STATE THAT I HAVE LEGAL CUSTODY OF THE AFOREMENTIONED MINOR. I GRANT MY AUTHORIZATION AND CONSENT FOR STODDARD COUNTY AMBULANCE DISTRICT (HEREAFTER "DESIGNATED ADULT") TO ADMINISTER GENERAL FIRST AID TREATMENT FOR ANY MINOR INJURIES OR ILLNESSES EXPERIENCED BY THE MINOR. IF THE INJURY OR ILLNESS IS LIFE THREATENING OR IN NEED OF EMERGENCY TREATMENT, I AUTHORIZE THE DESIGNATED ADULT TO SUMMON ANY AND ALL PROFESSIONAL EMERGENCY PERSONNEL TO ATTEND, TRANSPORT, AND TREAT THE MINOR AND TO ISSUE CONSENT FOR ANY X-RAY, ANESTHETIC, BLOOD TRANSFUSION,MEDICATION, OR OTHER MEDICAL DIAGNOSIS, TREATMENT, OR HOSPITAL CARE DEEMED ADVISABLE BY AND TO BE RENDERED UNDER THE GENERAL SUPERVISION OF ANY LICENSE PHYSICIAN, SURGEON, DENTIST, HOSPITAL OR MEDICAL PROFESSIONAL OR INSTITUTION DULY LICENSED TO PRACTICE IN THE STATE IN WHICH SUCH TREATMENT IS TO OCCUR. I AGREE TO ASSUME FISCAL RESPONSIBILITY FOR ALL EXPENSES OF SUCH CARE. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SUCH MEDICAL TREATMENT BUT IS GIVEN TO PROVIDE AUTHORITY AND POWER ON THE PART OF THE DESIGNATED ADULT IN THE EXERCISE OF HIS OR HER BEST JUDEMENT UPON THE ADVICE OF ANY SUCH MEDICAL OF EMERGENCY PERSONNEL. PLEASE TYPE FULL NAME OF PARENT OR GURADIAN. (required)

MEDIA AUTHORIZATION: I GIVE STODDARD COUNTY AMBULANCE DISTRICT AUTHORIZATION TO USE PHOTOS OR VIDEOS TAKEN DURING THE LIFE SAFETY PROGRAM FOR SOCIAL MEDIA PURPOSES. IT IS UNDERSTOOD THAT THESE PICTURES AND OR VIDEOS MAY BE POSTED TO THE DISTRICTS FACEBOOK, INSTAGRAM, AND OR WEBSITE. (required)

YES

NO

I HAVE READ AND UNDERSTAND AND AGREE TO AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL (GUARDIAN(S) AND MEDIA CONSENT FORM (required)

YES

NO

$25

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