WCCC Emergency Medical Authorization

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To enable parents/guardians to authorize the provision of emergency treatment for students who become ill or injured while under school authority when parents or guardians cannot be reached.

Career Technical Lab *

Grade *

Student First Name *

Student Last Name *

Date of Birth

YYYY

Street Address *

City *

State *

Zip *

Home Phone *

Please include the area code. If not applicable, please type "N/A"

Father's Name *

If not applicable, please type "N/A"

Father's Daytime Phone Number *

Please include the area code. If not applicable, please type "N/A"

Mother's Name *

If not applicable, please type "N/A"

Mother's Daytime Phone Number *

Please include the area code. If not applicable, please type "N/A"

Legal Guardian *

Please type first and last name. If not applicable, please type "N/A"

Legal Guardian's Phone Number *

Please include the area code. If not applicable, please type "N/A"

Parent/Guardian Email Address *

If not applicable, please type "N/A"

Student Resides With *

Custodial Parent *

EMERGENCY CONTACTS

Emergency Contact #1 *

In case of an emergency and neither parent can be reached, the school should contact (please list the names of LOCAL persons that can contact you in the event of an emergency or illness).

Relationship to Student #1 *

Daytime Phone #1 *

Permission to Pick up Student #1 *

Yes

Emergency Contact #2 *

In case of an emergency and neither parent can be reached, the school should contact (please list the names of LOCAL persons that can contact you in the event of an emergency or illness).

Relationship to Student #2 *

Daytime Phone #2 *

Permission to Pick up student #2 *

Yes

Emergency Contact #3

If not applicable, please type "N/A"

Relationship to Student #3

If not applicable, please type "N/A"

Daytime Phone #3

If not applicable, please type "N/A"

Permission to Pick up Student #3

If not applicable, please type "N/A"

Yes

Clear selection

Student Medical Facts

Facts concerning the student's medical history, including allergies, medications begin taken and any physical impairment to which WCCC or a physician should be alerted.

List all medical conditions *

If not applicable, please type "N/A"

List all medicines taken daily *

If not applicable, please type "N/A"

List all medicine allergies *

If not applicable, please type "N/A"

List all food and environmental allergies *

If not applicable, please type "N/A"

Treatment for the above allergies *

If not applicable, please type "N/A"

Does the student wear contacts or glasses? *

List all vision and/or hearing problems *

If not applicable, please type "N/A"

Date of Current Tetanus Immunization *

We request that tetanus be current. If not applicable, please type "N/A".

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

Part 1 or Part 2 - *

Please choose one.

PART 1: to GRANT CONSENT - I hereby give consent for WCCC to have my child transported to hospital/clinic for emergency medical care or to dental emergency facility for dental care or the nearest available source of assistance

PART 2: I DO NOT give WCCC my permission to have my child transported for emergency medical/dental care. In the event of an illness or injury which requires medical or dental treatment, I wish for the following action to be taken

PART 2 - Action *

If you chose PART 2 above, please list the actions below that you would like for WCCC to follow. If not applicable, please type "N/A".

Comments or concerns about the student's health of which the school should be aware *

If not applicable, please type "N/A"

List all medical facts regarding the student *

Facts concerning the student's medical history, including allergies, medications being taken and any physical impairment to which a physician should be alerted

Physician Name *

Physician Phone Number *

Dentist Name *

Dentist Phone Number *

Specialist Name

If not applicable, please type "N/A"

Specialist Phone Number

If not applicable, please type "N/A"

Preferred Hospital *

FIELD TRIP PERMISSION

FIELD TRIP PERMISSION (parent initials) *

I give my student permission to attend all field trips associated with Warren County Career Center for this school year. This includes field trips with classes, bus trips, extracurricular trips, etc. I understand most trips are taken on district owned vehicles driven by Petermann Bus Services. ALL SCHOOL RULES AND POLICIES ARE IN EFFECT ON EVERY FIELD TRIP. By typing my initials, I grant permission for my child to be transported by a school bus or other district owned vehicle driven by Petermann Bus Services. I also agree with all the above field trip information and I understand that the Board of Education, the School Administrators, advisors, teachers, etc. assumes no liability for the trip(s).

I understand that by typing my name below, I deem that all information is correct and that I am electronically signing this document.

Parent/Guardian Signature *

Parent Address, City, Zip *

Date *

YYYY

Submit

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