[Print this form, complete, and return to the
school office] Child's Name:___________________ Grade___ Birthdate_______
Address____________________________________ Home Phone___________
Mother's Name_______________________ Work Phone_____________ Work
Place___________________
Father's Name_______________________ Work Phone_____________ Work
Place___________________
Physician's Name____________________ Phone_______________
Health Insurance Co._______________________
Medical Plan #______________________
Dental Plan_______________________ Dentist's Name_______________________
Phone_____________
If I am unavailable during an emergency, please call:
Name________________________ Phone (h)____________ (w)____________
Relationship___________
Name________________________ PHone (h)____________ (w)____________
Relationship___________
These persons are authorized to take my child from the school:
Name________________________ Phone (h)____________ (w)____________
Relationship___________
Name________________________ Phone (h)____________ (w)____________
Relationship___________
In the event of an emergency when a parent/guardian is unavailable, I hereby
authorize a representative of the school to make such arrangements as considered necessary
for my child to receive medical or hospital care, including transportation. Under such
circumstances, I further authorize the physician named above to undertake such care and
treatment of my child as considered necessary. In the event said physician is not
available, I authorize such care and treatment to be performed by any licensed physician
or surgeon.
Parent/Guardian Signature______________________________ Date_____________________
