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Emergency Form (one per family)

EMERGENCY FORM

School Year 2021-2022

 

PLEASE FILL OUT COMPLETELY AND ACCURATELY, AS THIS INFORMATION WILL BE USED IF YOUR CHILD BECOMES INJURED OR IS IN NEED OF EMERGENCY MEDICAL ATTENTION.

 

*Please list children from oldest to youngest.

PRIMARY FAMILY INFORMATION:

State
Answer Required
State
Answer Required

Emergency Contact Information

Please be sure to let your emergency contact person know that you have listed them as the “contact person” for your child(ren).  They will be contacted should we be unable to reach you. 

In the event that neither you or your emergency contact can be reached, please list a physician that the school may contact to follow his or her instructions.  If your physician cannot be reached, the school will make whatever arrangements are necessary.

State
Answer Required

I authorize the physician, dentist, and/or hospital listed on this document to treat my child in the event of serious illness or injury, when I or the persons listed on this form cannot be reached.  Any obligation for medical expenses resulting from treatment in such a case is my responsibility.  Permission to transport my child in case of emergency is also given.

By signing this form, we attest that we provided the above information and that it is accurate to the best of our knowledge.

Confirmation Email