Permission for Treatment/Risk Notification
Authorization for Medical Care:
In the event of a medical emergency or illness, I hereby authorize Greenwich Public Schools to provide First Aid, and/or to request emergency medical treatment and transportation to a hospital.  Any hospital or emergency medical personnel are authorized to provide treatment to my child of such nature as they deem appropriate and to consult with the physician listed in the Student Profile.

* I understand that COVID-19 is a contagious disease that may continue to be present in the Greenwich community, and that all reasonable precautions have been taken by the school district to mitigate the spread by adhering to the latest guidelines as put forth by the CDC and the State Department of Public Health. With that, I understand and acknowledge that there will be a level of risk of contagion as would be accepted in any public venue.

** A child without a history of a severe allergic reaction may receive epinephrine from a certified teacher if a reaction is suspected (CT. Act 14-176). Please contact the nurse directly, if you do NOT wish your child to be included under this law.

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School *
Student Name *
Grade *
Emergency Contact Name (other than parent/guardian) AND Phone Number *
Parent Name *
Parent/Guardian Signature: by electronically signing this document I agree to the terms stated above. *
Date: *
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Student's Doctor's Name: *
Student's Doctor's Telephone #: *
Student's Dentist's Name: *
Student's Dentist's Telephone #: *
Emergency Number for Parent: *
Child Health Insurance Information
THIS SECTION IS REQUIRED BY THE STATE
Does Your Child Have Health Insurance *
If your child is uninsured we will provide you information on Connecticut's HUSKY Plan.  Your electronic signature means that the school can provide you with contact information for the Connecticut Department of Social Service (administering the HUSKY Plan) or information about how to enroll in HUSKY.
Parent/Guardian Electronic Signature: *
Date: *
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