FAMILY NAME PARENT / LEGAL GUARDIAN'S NAME HOME ADDRESS (street, city, zip code)EMAIL HOME PHONE CELL/ALT PHONE STUDENT #1 AGE BIRTH DATE (MM/DD/YY)ALLERGIES / SPECIAL NEEDS GRADE (2010/11) GROUP WITH
OVER THE COUNTER AND/OR PRESCRIPTION DRUGS TAKEN REGULARLY STUDENT #2 AGE BIRTH DATE (MM/DD/YY)ALLERGIES / SPECIAL NEEDS GRADE (2010/11) GROUP WITH
OVER THE COUNTER AND/OR PRESCRIPTION DRUGS TAKEN REGULARLY STUDENT #3 AGE BIRTH DATE (MM/DD/YY)ALLERGIES / SPECIAL NEEDS GRADE (2010/11) GROUP WITH
OVER THE COUNTER AND/OR PRESCRIPTION DRUGS TAKEN REGULARLY STUDENT #4 AGE BIRTH DATE (MM/DD/YY)ALLERGIES / SPECIAL NEEDS GRADE (2010/11) GROUP WITH
OVER THE COUNTER AND/OR PRESCRIPTION DRUGS TAKEN REGULARLY
MEDICAL RELEASE
In an emergency, reasonable effort will be made to contact the parent or legal guardian listed above. If they cannot be reached, please contact:
NAME RELATIONSHIP TO CHILD CELL / ALT PHONE HOME PHONE
PRIMARY INSURANCE COMPANY PHONE
POLICY HOLDER'S NAME RELATIONSHIP TO CHILD
POLICY ID NUMBER GROUP / POLICY NUMBER
Statement of Consent
In the event of an emergency or non-emergency situation requiring medical treatment, I __________ hereby grant permission for any and all medical and/or dental attention to be adminstered to my child in the event of an accidental injury or illness. I understand that every effort will be made to contact me through all provided contact information. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and and the adminstration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.
Signature:____________________________ Date:_______________
By checking this box, you agree to the Statement of Consent.
Person filling out form Parent Legal Guardian