Cobb County School District "Blanket" Permission To Participate Form/medical History Permission And Release Form/etc. Page 3

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NW Metro Atlanta Habitat for Humanity
Previous operations or serious illnesses ____________________________________________
Any current medications ________________________________________________________
Special Diet (name) ____________________________________________________________
Childhood Diseases: Chicken Pox ____ Measles ____ Mumps ____ Whooping Cough_____
Any medical needs which your child has, of which adult supervisors should be aware:
PERMISSION FOR TREATMENT
My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my
student.
I release and waive, and further agree to indemnify, hold harmless or reimburse the Cobb County School District, the
Board of Education, its successors and assigns, its members, agents, employees, and representative thereof, as well as trip
supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the student, or any other
person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, from any losses,
damages or injuries arising out of, during or in connection with the student’s participation in the trip or the rendering of
emergency medical procedures or treatment, if any.
DATED _____________________
____________________________________________ NOTARY _____________________
Signature of Parent/Guardian
5/12/04
Cobb County School District
Form CFIA-1
Page 3 of 7
Waiver/Release Form v4.2014

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