CCSD Medical Authorization Form
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Email *
Student First Name *
Student Last Name *
Indicate which group/s you participate in  *
Required
Parent/Guardian Home Phone *
Parent/Guardian Work Phone *
Alternate Emergency Phone Number *
Insurance Company *
Insurance Policy Number *
List and allergies, medications, or other medical problems for your student.
My child has an individualized Healthcare Plan ("IHP"), Section 504 plan, or IEP.
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If yes, I have discussed this plan with the sponsor of this activity.
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I/We, the undersigned Parents/Guardians of the above-named Student, understand that Student may need medical attention during 2022-2023 Band field trips or activities.  I/We hereby give our consent and permission for the above-named Student to (1) be treated by any medical provider, nurse, physician, or surgeon as may be deemed necessary by CCSD, its agents, servants, or employees during the trip or activity; (2) be administered medication and or emergency first aid care by CCSD staff as may be necessary, appropriate or planned for; (3) receive treatment in hospitals, medical offices, clinics or elsewhere in the event of accident or illness.  In the event that Student needs such medical attention, CCSD staff will attempt to contact me/us or other people named on this form.  Additionally, I/We hereby understand that CCSD staff will grant and authorize CCSD staff to take whatever action is deemed necessary in their judgement for the medical or emergency healthcare treatment of aforesaid Student.  I/We understand that the District does not provide health or medical insurance for students.  I/We further understand that I/We are responsible for payment of all health, medical and emergency care treatment provided for my child while participating on this trip.  I/We understand and agree that neither the CCSD nor its agents, servants or employees are responsible for obtaining or for the result of any medical or emergency treatment rendered or supplied to the student.  I/We further agree to indemnify, hold harmless and defend Cherry Creek School District, from any claim, cause of action or demand, of any sort or nature, which may at any time be filed or asserted arising out of any form of the lack of medical or emergency treatment rendered to the Student. *
I agree and understand that by signing this Medical Authorization Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Parent/Guardian Name (First, Last)
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