Pf Appco & H Rco Fom mus b f ou o vw sg c y fo ppc o b offcy cogz Poomc Cofc Pf Appc s Dmogpc (Ps P) Nm: Pmy Coc Numb: (Ls) (Fs) (Ps s umb w w c c you 24/7) Ass: DOB: E-M: Cy: Scoo: S: Zp Co: Po: G: P/Gu Dmogpc F/Gu: E-M: Wok Ass: Po: Mo/Gu: E-M: Wok Ass: Po: F=s C Po: Mo=s C Po: Pckup Auozo Ps s pso(s) uoz o pck up you c fom Pf fucos. Ps/Gus you c w b s fom Pf fucos oy o psos s bov. If o gms cssy o mus ccompy you c c mus b m o Cub Dco po o Pf fuco. No xcpos! Tk you fo you coopo. Ps/ Gus W P/Gus of bov m Pf ppc v Pf Pg Lw us objcv of s Pf cub sous bov m bcom Pf. W w sss ppc w obsvc of us ou usg mg Pf Pg Lw s w s sssg w objcvs of s Pf Cub. W so wv y cms gs Cub Lsp Pf Cub Cofc Uo o No Amc Dvso of Sv-y Avs fo y ccs wc my s coco w cvs of s Pf Cub s pm by w. I /w so us my c my b poogp o vo p I/w s gs fo pcu o vo o b us fo p poogpc vo gpc wb pubcos vsg s pm by w. W so us s ocum my b cop fo msv puposs w usg fomo w b poc u HIPPA s. Ps/Gus Sgu: D:
Mc Hsoy Ifomo T foowg fomo s cc fo sf c of you Pf ug ou Pf cvs mgcs. Ps sw qusos s o ys o o & f ys xp w o fomo. Y N Dos you c v y soy? (Asm Cospo Eppsy Dbs c) Dos you c v y ffcus wou ffc m ug Pf cvs? Dos you c v y gs o mcos? Ps s w co. Dos you c v y gs o foos scs o sso? Ps s w co. A y y cosos wc sou b cos w pg mu? A y pysc scos wou ffc you c ug Pf cvs? A Pfs qu o v up o so cos y sos o? Is you c cuy o y mcos? If Ays@ ps s w osg. Isuc/Pysc/Emgcy Coc Ifomo Pmy Pysc: Emgcy Coc: Po: Po: Mc Isuc: Numb: (Ps pov Pf Cub copy of suc c) Bg Ps/Gus of ppc I/w cfy bov mc soy fomo s coc o bs of ou kowg ppc s pmsso o gg Pf cvs xcp os o. I/w gv pmsso o s gs mc cosos mcos o ppc s ID c qu by cofc pov by cub o b wo Cofc cvs. I v I/w co b c mgcy pmsso s gv o u o wom ppc s cg o ospz scu pop ss o pysc o jco sugy susco o y c m cssy by o pysc o su sf u of s ppc o s/ Ps/Gus. I/w so us poocops of s ocum s v sm foc ffc s og w Cub Dco o H C Sff ss og fom s s v s o b vok by us s p/gu. P/Gu: D: w Fom Rvw Sgu (Ps vw up sg c subsqu y) P/Gu: D: P/Gu: D: P/Gu: D: P/Gu: D: Rvso: Juy 2016
PERMISSION TO LIST MEDICAL INFORMATION ON PATHFINDER S IDENTIFICATION CARD D Pf Cub Nm Cuc Pf Cub Dco I (p o gu) gv pmsso fo bov (p m) s Pf Cub Dco o s gs mc cosos mcos fo my c (Pf s m) o my c s (p m) Pf Cub fco c. P o Gu sgu 8/2015
GENERAL PERMISSION SLIP Pf Cub Pf s m Pf Ifomo (p m) B Emgcy Ifomo (ps p) P 1 Coc Ifomo: Ro o Pf Po Numbs: (Hom) (C) (Wok) P 2 Coc Ifomo: Ro o Pf Po Numbs: (Hom) (C) (Wok) Emgcy Coc: Ro o Pf Po umbs: (Hom) (C) (Wok) PERMISSION AND EMERGENCY TREATMENT RELEASE I (w) usg g pmsso fo bov s pf o y Tkom Pk Rgs Pf v. I (w) us v mc m s qu vy ffo w b m o coc m. Howv f I co b c I gv my pmsso o pf sff o sg o scu svcs of cs pysc o pov c cssy cug ss fo my c s w bg. I so us I w o o pf ogzo o sposo sposb fo y cc wc mg occu. P s sgu D Poocops Aow: Poocops of bo H Rcos H C Rs foms s v sm foc ffc s og w Cub Dco o H C Sff ss og fom s s v s o b vok by p o g gu of mo. 8/2016
Vogpy/Poogpy Rs Fom Ts cofms gm bw you Tkom Pk Sv-Dy Avs Cuc gg you pcpo ppov Tkom Pk Rg cvs wc you my b poogp o vop ( Popy) fom m o m. Fo vub coso cv you by vocby g o Tkom Pk Sv- Dy Avs Cuc ppuy xcusvy fo m ougou wo (cug p o c om vo CD-ROM y o coc mum psy xsc o v fuu) g o us copo (o o og w o ms) wo o p poogps o vo foog k of you s su of you pcpo ppov cvs of Tkom Pk Rgs. You by g you w o bg o cos o os bgg cm o co gs Tkom Pk Sv-Dy Avs Cuc o gous yg co Popy o vsg pubcy us coco w s fmoy fcs vsy o you vos y o g wsov cug wou mo gs of pvcy pubcy. You by s Tkom Pk Sv-Dy Avs Cuc s cos offcs succssos ssgs fom gs y cms ms cos cuss of co sus coss xpss bs mgs wsov you my f v gs Tkom Pk Sv-Dy Avs Cuc coco w Popy. Ts gm s o obg Tkom Pk Sv-Dy Avs Cuc o us Popy o o us y of gs g u o o pp pouc xb sbu o xpo Popy. T Tkom Pk Sv-Dy Avs Cuc s v g o ssg s gs u wou you cos wo o p o y pso fm o copoo. AGREED TO AND ACCEPTED s y of 20 Pcp s Sgu Sgu of P o Gu f u 18 P m of Pcp: Tpo Numb: ( )
P f P g B y g c ofgo I w b p u k u. I w k p P f L w. I w b s v ofgo A f om. P f L w T L w sf om o: K p mo gw c Domy o s p C f omyb o y K p v y B c ou ou s ob W ks of y s c u y K ps o g my GooGo ' s s.
PERMISSION SLIP Pf Cub Ev W:(s ss) W: (D m sp f o y v o Dpu Ru m) Pf Ifomo Pf s m B (p m) Emgcy Ifomo (ps p) P 1 Coc Ifomo: Ro o Pf Po Numbs: (Hom) (C) (Wok) P 2 Coc Ifomo: Ro o Pf Po Numbs: (Hom) (C) (Wok) Emgcy Coc: Ro o Pf Po umbs: (Hom) (C) (Wok) PERMISSION AND EMERGENCY TREATMENT RELEASE I (w) usg g pmsso fo bov s pf o s v. I (w) us v mc m s qu vy ffo w b m o coc m. Howv f I co b c I gv my pmsso o pf sff o sg o scu svcs of cs pysc o pov c cssy cug ss fo my c s w bg. I so us I w o o pf ogzo o sposo sposb fo y cc wc mg occu. P s sgu D Poocops Aow: Poocops of bo H Rcos H C Rs foms s v sm foc ffc s og w Cub Dco o H C Sff ss og fom s s v s o b vok by p o g gu of mo. Juy 2016