| I have been examined by a member of Hampshire College EMS and I am aware of the nature and extent of my injuries and the possible consequences of my refusing any further medical treatment. I agree not to hold liable Hampshire College EMS or any of its agents for the foreseeable consequences of not seeking further medical care. |
| I have read and understand the above release. |
| Signature | ____________________________________ |
| Date | ____________________________________ |
| EMT | ____________________________________ |
| Witness | ____________________________________ |
| HCEMS # | ____________________________________ |
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