Fillable Missouri Fccla Sample Medical Release Form (Page 2 of 2) in pdf

Missouri Fccla Sample Medical Release Form Page 2

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If parent/guardian cannot be reached in case of emergency, call:

___________________________________

(_____ ) __________________________

First Choice Name

Area Code Phone

___________________________________

(_____ ) __________________________

Second Choice Name

Area Code Phone

In a medical emergency, I consent to the local/state advisor or appointed agent, his, her or their discretion in using, taking, arranging for or

consenting to the procedures or treatment.

I agree to indemnify and hold harmless the ___________________ Family, Career and Community Leaders of America, the individual

members, agents, employees and representatives thereof, for any and all claims, demands, actions, rights of action, and/or judgments by or

on behalf of the above named member arising from or on account of said procedures and/or treatment rendered in good faith and

according to accepted medical standards.

I assume the total financial responsibility for the above named member and will not hold the _________________ Family, Career and

Community Leaders of America responsible in the event of a medical emergency.

_________________________________________

________________________________________________

Signature of Parent/Guardian

Date

_________________________________________

Social Security Number of Parent/Guardian (optional)

It is the policy of the Missouri Department of Elementary and Secondary Education not to discriminate on the basis of race, color, religion, gender,

national origin, age, or disability in its programs or employment practices as required by Title VI and VII of the Civil Rights Act of 1964, Title IX of the

Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975 and Title II of the Americans with

Disabilities Act of 1990. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons

with disabilities may be directed to the Jefferson State Office Building, Office of the General Counsel, Coordinator–Civil Rights Compliance

(Title VI/Title IX/504/ADA/Age Act), 6th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number (573) 526-4757

or TTY (800) 735-2966, fax (573) 522-4883, email civilrights@dese.mo.gov.