Child Emergency Medical Form

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

SCHOOL YEAR 2022-23

Student Information

Emergency Contact Information

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

Enter the number with dashes as shown
Enter the number with dashes as shown
Enter the number with dashes as shown

Medical History

Does your child have allergies? *

(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:

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: