Mrs. Rickman

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VIEW: Home \| Job Shadowing Medical Form \| Announcements \| Orientation \| Counseling \| Scheduling \| 5th Grade Activities \| 6th Grade Activities \| 7th Grade Activities \| 8th Grade Activities \| Study Skills \| DMS Beta Club \| DMS Beta Convention Information \| Beta Club News \| Job Shadowing Application \| Job Shadowing Permission Slip \| Career \| Testing \| Parenting \| Personal/Social Link \| Academic Links \| Games \| About The Counselors \| Schedule \| Grade 6 \| Grade 7 \| Grade 8 \| DMS Beta Club Calendar \| Grade 5

Visit the TeacherWeb® videos to learn about the features, modifications, and customizations available on your website. Click here to learn more. Job Shadowing Medical Form small medium large EDUCATION EDGE JOB SHADOWING Medical Authorization Form MEDICAL AUTHORIZATION Should it be necessary for my child to have medical treatment while participating in Job Shadowing, I hereby give the school district personnel or the below named company permission to use their best judgment in obtaining medical services for my child, and I give permission to the physician selected by school district personnel or the company to render whatever medical treatment he or she deems necessary and appropriate. Permission is also granted to release necessary emergency contact/medical history to the attending physician, the school system, or to the host company, if needed. Company Name: __________________________________ Job Shadow Date: May 12, 2010 Name of Workplace Host:__________________________ Student's Name:_________________________________________________________ Date of Birth:____________________________________________________________ Address:______________________________________________________________ Home Phone:___________________________________________________________ Daytime phone contact information for parent(s) or guardian: ________________ Contact other than parent/guardian: _____________________ Relation to Student:____________________________Phone:____________________ Family Doctor:________________________________Phone:_____________________ Preferred Hospital:_______________________________________________________ Hospital Address:________________________________________________________ Hospital Phone:__________________________________________________________ Does your child require any special accommodations due to medical limitations, disability, dietary constraints, or other restrictions? If yes, please explain. ______________________________________________________________________ ______________________________________________________________________ I hereby agree to all of the above authorizations and permissions. ______________________________________________________ Signature of Parent/Guardian Or, would you like to view and optionally restore one of these previous versions? Password: Forgot your password?

Mrs. Rickman

Job Shadowing Medical Form

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