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									                                                    BEATRICE


                                  BOMBERS
                                        FOOTBALL
                            BEATRICE BOMBERS FOOTBALL
                       MEDICAL TREATMENT POWER OF ATTORNEY
TO ALL PHYSICANS, HOSPITALS AND/OR MEDICAL PERSONNEL:

The undersigned, parent(s) or duly appointed and acting guardian(s) of ____________________________________,
                                                                                                 th
a minor child, pursuant to Neb. Rev. Stat. 30-2604, I/we hereby delegate to), Chad Jurgens (5 /6th Grade Coach), and
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Craig Wallman (3 /4th Grade Coach) who are designated Attorneys-in-Fact for this purpose, the authority to obtain all
necessary medical assistance and treatment for my/our son, named above, in the event of an emergency, including
but not limited to, the assistance of a physician and/or a hospital. This delegation is granted for the purpose of
providing emergency medical assistance and treatment when the parent or guardian is not present or immediately
available.

This delegation is made for the period of 6 months beginning on August 1, 2012.

MEDICAL INFORMATION:

Please check any of the following which may be applicable (describe if necessary):

        _____ Glasses or Contact Lenses                         _____ Requires daily medication (List)
        _____ Asthma                                            ____________________________________
        _____ Diabetes                                          ____________________________________
        _____ Epilepsy                                          _____ Orthopedic Information
        _____ Allergies                                         ____________________________________
        _____ Hearing deficiencies                              ____________________________________
        _____ Other

Additional Information:____________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Health Insurer:____________________________________________ Policy Number: _________________________

Employer Furnished Policy – Employer Name:_________________________________________________________


_____________________________________________________                             _____________________________
                  Parent/Guardian Signature                                                     Date

_____________________________________________________                             _____________________________
                  Parent/Guardian Signature                                                     Date

NOTE: BOTH PARENTS AND ALL GUARDIANS ARE REQUIRED TO SIGN THIS FORM.                                    Page 4

								
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