It's never too early to start thinking about summer! Join one of our many summer programs to have some fun and enjoy learning opportunities unique to each student's likes and interests.
Read more

ATHLETICS: Emergency Medical Authorization


 

Student Name
  •  
Date of Birth //
  •  
Sex
  •  
Grade
  •  
Address
  •  
Living with Family?
  •  
Mother or Guardian
  •  
Father or Guardian
  •  
Mother's Phone -- ext
  •  
Father's Phone -- ext
  •  
Primary E-mail
  •  
Secondary E-mail
  •  
Extracurricular Activities
  •  
If I cannot be contacted and it is advisable to send my child home due to minor illness or injury, my child can be released in the custody of:
Primary Contact
  •  
Primary Phone -- ext
  •  
Secondary Contact
  •  
Secondary Phone -- ext
  •  
Tertiary Contact
  •  
Tertiary Phone -- ext
  •  
Medical Contacts
Preferred Physician
  •  
Preferred Dentist
  •  
Preferred Hospital
  •  
Insurance Carrier
  •  
Insurance Number
  •  
PART I: To Grant Consent (PART I or PART II)
In the event reasonable attempts to contact me (at the primary phone number) or the other parent or guardian (at the secondary phone number) have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed by my preferred physician or preferred dentist, or in the event this designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to my preferred hosptial or any hospital reasonably accessible. This Authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring on the necessity of such surgery, are obtained prior to the performance of the surgery.
Text (Multiple Lines)
  •  
Parent or Guardian Name
  •  
Date //
  •  
PART II: Refusal to Consent (PART I or PART II)
I do not give my consent for emergency treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to:
Text (Multiple Lines)
  •  
Parent or Guardian Name
  •  
Date //
  •