SCHOOL YEAR 2022-23
Student Information
Emergency Contact Information
Provide local person(s) to be called in case the parent/guardian cannot be reached:
Medical History
(Note: Teachers are not authorized to administer medicines or provide medical related services.)
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: