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This form is provided for the medical and liability release regarding the necessary medical care and treatment to be administered to people attending the State HOSA Conference.
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MEDICAL / LIABILITY RELEASE and CONDUCT CODE AGREEMENT FORM
Due to legal restrictions, it is necessary that all students, chaperones, and HOSA Advisors complete
this form as a prerequisite for eligibility to attend the State HOSA Conference. Chapter Advisor,
please make a copy for your files and mail the originals to the State Conference Manager.
PLEASE TYPE OR PRINT ALL INFORMATION
Name _________________________________________________________________________
(Circle title) Advisor Alumni Chaperone Student Professional
Home Address __________________________________ Home # (_____)________________
City ___________________________________________ Zip ____________________
Parent/Guardian's Name ___________________________________________________________
(If appropriate)
Father Work # (_____)______________________ Mother Work #(_____)___________________