Child Emergency Medical Form

Note: You have the option to print the Child Emergency Medical Form

SCHOOL YEAR 2022-23

Student Information

Student Name (First/Last): *

Emergency Contact Information

Provide local person(s) to be called in case the parent/guardian cannot be reached:

Emergency Contact Name 1: *

Emergency Contact Name 2:

Emergency Contact Name 3:

Phone Number 1: *

Phone Number 2:

Phone Number 3:

Medical History

Does your child have allergies? *

Yes

If yes, please list allergies your child has:

(Note: Teachers are not authorized to administer medicines or provide medical related services.)

Are there any medical condition(s) that the school needs to be aware of:

Yes

If yes, please explain in detail.

Medical Treatment

If the parent/guardian cannot be reached in case of serious injury or illness, I authorize the school to take such emergency action necessary, including the transportation of the student to a hospital or medical center. As a parent/guardian, I authorize treatment by a qualified and licensed medical doctor of the above listed minor(s) in the event of a medical emergency. This authority is granted only after a reasonable effort has been made to contact me

Signature Agreement:

By checking this box, I agree to the use of my electronic signature and agree that the electronic signature is valid and has the same effect as a written signature on a paper copy of this document.

Print name of parent/guardian *

Date *

Thank you. Your Emergency Consent form has been submitted for the school year 2022-23.

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