JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Emergency Contact and Medical Release Form
* Indicates required question
Name of student #1:
*
Your answer
Student's birthdate:
*
MM
/
DD
/
YYYY
Name of student #2:
Your answer
Student's birthdate:
MM
/
DD
/
YYYY
Name of student #3:
Your answer
Student's birthdate:
MM
/
DD
/
YYYY
Name of student #4:
Your answer
Student's birthdate:
MM
/
DD
/
YYYY
Name of student #5:
Your answer
Student's birthdate:
MM
/
DD
/
YYYY
IN CASE OF EMERGENCY, THE CONTACT PERSON IS: (parents will always be contacted first, this should be who you want us to contact if parents can't be reached)
*
Your answer
Emergency Contact Person's Cell Number:
*
Your answer
I give High Street Christian Academy permission to give my child(ren) the following medicines if needed:
*
Tylenol
Ibuprofen
Benadryl
Pepto Bismol
Medicine from home (if a note is sent)
Other:
Required
Please list any allergies or medical conditions of your child(ren):
*
Your answer
Has your child(ren) been immunized? If yes, please list.
*
Your answer
Has your child(ren) been diagnosed with any medical conditions or illnesses? If yes, please explain.
*
Your answer
Does your child(ren) take medication for any reason? If yes, please explain.
*
Your answer
Does your child(ren) have any other physical, mental, or emotional problems we should be aware of? If yes, please explain.
*
Your answer
The administration of High Street Christian Academy has my/our permission to have any emergency doctor, hospital, dental, or other needed medical care administered to my/our child(ren).
Signature of Father:
*
Your answer
Signature of Mother:
*
Your answer
Signature of Guardian: (if applicable)
Your answer
Date:
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
