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Future Health Professionals Consent Form

***If this is an emergency or you are experiencing chest pain, shortness of breath, or an allergic reaction, please call 911 or report to your closest Emergency Room immediately. Do not use this form for urgent medical needs.

 

PARENTS/GUARDIANS:  Please read all of the statements before giving your approval for participation in the activity listed above. I hereby approve and agree to all the terms, conditions, and waiver of claims of this CONSENT FORM and certify to its correctness. Further, I agree that this Student/Participant can meet the health and physical fitness requirements of the activity, which may include trips off-site of the Regional Medical Center premises.  I give consent for Inspira Health Network to take and use photographs, videos and audio recordings of my child and to interview my child for publicity, educational marketing, advertising, and fundraising purposes through internal publication, external publication, radio, television, video or internet.  I hereby waive my right to inspect or approve the final product than may be used, or to be informed of its use.

 

Name
May we send you health information by email?
Address
Ethnicity
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