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Fill and Sign the Nc Secretary of State Financial Power of Attorney Form

Fill and Sign the Nc Secretary of State Financial Power of Attorney Form

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THE SCHOOL BOARD OF POLK COUNTY STUDENT ACCIDENT REPORT FORM Name ____________________________ Home Address _________________________________________________ School ____________________________________________________ Sex: M Time Accident Occurred: Hour ________ A.M. ________ P.M. Place of Accident: School Building _____ F Age: _____ Grade ________ Date __________________________________ School Grounds _____ To or From School ________ DESCRIPTION OF THE ACCIDENT List student activity at time of accident, location on campus of accident , list any equipment, tool, or machinery that was involved. Describe in detail the events leading up to the accident, and the accident itself: ____________________________________________________________________________________________________ ________ ____________________________________________________________________________________________________ ________ ____________________________________________________________________________________________________ ________ ____________________________________________________________________________________________________ ________ ADDITIONAL INFORMATION Teacher in charge when the accident occurred ______________________________________________________________ Present at the scene of accident ____ Yes ____No Direct Blood Contact ____Yes ____ No Persons involved __________________________________________________ First Aid Treatment _____ By (Name) ___________________________________________________________________ Sent to School Nurse ____ By (Name) ___________________________________________________________________ Sent Home _____ By (Name) ____________________________________________________________________ Sent to Physician _____ By (Name) ___________________________________________________________________ Physician’s Name: ___________________________________________________________________________________ Sent to the Hospital ____ By (Name) ___________________________________________________________________ Was a parent or other individual notified? ____ Yes ____ No When? __________ How? _________________________ Name of individual notified: ___________________________________________________________________________ By whom? (Enter Name) ______________________________________________________________________________ Witnesses: 1. ______________________________________ 2. ____________________________________________ 3. ______________________________________ 4. ____________________________________________ REMARKS In all occurrences of direct blood contact, persons involved or responsible persons should be informed that confidential information concerning HIV and Hepatitis is not available from or through Polk County Schools. Principal ___________________________ Date ________ Teacher __________________________ Date _________

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