2023-2024 SCESC Student Services Registration
Emergency Medical Authorization Form
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Email *
Untitled Title
STUDENT INFORMATION
Please complete all required fields.
Student Last Name *
Student First Name *
Student Middle Name *
Student Gender *
Student School District of Registration *
Student Grade *
Enrollment Site *
Date of Birth *
MM
/
DD
/
YYYY
Student Address: Street Number,Street Name, City, Zipcode *
Student Social Security Number
EMERGENCY CONTACT INFORMATION
Enter at least one emergency contact person below. Add the phone number and choose a description for that person. If there are additional emergency contacts, you may add up to four total.
Contact Name 1 *
Contact Phone 1 *
Enter phone number below
Contact 1 Description *
Contact Name 2
Contact Phone 2
Enter phone number below
Contact 2 Description
Contact Name 3
Contact Phone 3
Enter phone number below
Contact 3 Description
Contact Name 4
Contact Phone 4
Enter phone number below
Contact 4 Description
Additional Person(s) authorized to pick up child and contact number *
No Contact
If applicable, list full name of any person who has no legal right to have contact.
MEDICAL INFORMATION
Provide any information to insure the safety of your child in the event of an accident.
I give permission for the school to administer an OTC ibuprofren.  *
Physician Name *
Physician Phone *
Dentist Name *
Dentist Phone *
Medical Specialist Name
Medical Specialist Phone
Preferred Hospital *
Please provide information concerning the child’s medical history including allergies, medications being taken and any physical impairments to which a physician should be alerted:
Health Insurance/Medicaid Provider Card Holder Name
Health Insurance/Medicaid Provider
Health Insurance Provider/Medicaid Number
In the event reasonable attempts to contact a parent/guardian have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by the designated preferred physician or dentist, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist, and the transfer of the child to the preferred hospital or any hospital reasonably accessible. *
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