Seoul Foreign School Medical Waiver Form
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1Medical Waiver Form
I, the parent/guardian (name) _______________________ do hereby grant permission for (student name)
_____________________ to participate in the following school sponsored event _____________________________ .
STUDENT INFORMATION:
Date of Birth: Yr/Mo/Day____________________
Social Security #: ______________________
Hospital of choice for treatment in Seoul: _______________________________________________________
INJURY WAIVER
If an injury should occur to this student while on the activity described above, I will not hold the school or its
personnel responsible beyond the limits of the accident insurance policies of the school. I understand that the
policies are available for my inspection at the Business Office of the school.
MEDICAL TREATMENT AUTHORIZATION
This is to authorize the Seoul Foreign School adult chaperone(s) during the activity mentioned above the right to
request and approve needed medical treatment of this student.
Limitations (if any):
_______________________________________________________________________________________________
CONTACT INFORMATION
Home Phone: ________________________
Work Phone: _______________________
Cell Phone: _______________________
PLEASE PROVIDE THE NAME AND PHONE NUMBER OF SOMEONE ELSE WE CAN CONTACT IN AN EMERGENCY IF WE
CANNOT REACH ANYONE AT HOME OR WORK.
Name ______________________________
Phone Number _______________________
Both the parent/guardian and student must sign below for trip authorization.
Parent Signature _____________________
Date _____________________
Student Signature _____________________
Date _____________________
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Parent category: Medical