Cell/Primary Contact number for "Other Emergency Contact" *
Your answer
Student's Physician *
Your answer
Physician's Office Number *
Your answer
Physician's Exchange or after hours number *
Your answer
Name of Insurance Company *
Your answer
Group Number *
Your answer
Policy Number *
Your answer
Date of last Tetanus shot *
MM
/
DD
/
YYYY
Does the student have any allergies, special health needs, or require medical care of any type. (Including current medication) *
Choose
Yes
No
If "Yes" please explain (If currently on medication, please list - When to take it, how much, and how often)
Your answer
I/We understand and authorize in the event of an emergency or medical problem, a faculty member, school administrator, or the accompanying chaperone are empowered to make a decision regarding hospitalization and retention of a medical doctor. *
Choose
Yes
No
I hereby authorize the emergency treatment, administration of anesthesia and surgical treatment of my minor child, in the event of an emergency medical situation occurring during my absence or when hospital/medical authorities are unable to contact me. I release from responsibility and liability hospital/medical authorities for performing medical procedures deemed necessary during my absence. *
Choose
Yes
No
Today's Date *
MM
/
DD
/
YYYY
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