STUDENT INFORMATION:
PARENT/GUARDIAN INFORMATION(STUDENT RESIDES WITH):
Does your student require:
OTHER PARENT/GUARDIAN INFORMATION:
LIST BELOW NAMES OF THREE (3) PERSONS WHO MAY BE CALLED IN CASE OF EMERGENCY OR IF CHILD IS SICK AND YOU ARE NOT ABLE TO BE REACHED.
TO ANY DOCTOR OR HOSPITAL: In case | or any other contacts can not be reached in the case of an emergency, I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anestnesia, or surgery for my child as name above my, My signature below constitutes authorization to perform any necessary treatment for my child in an emergency.