Medical Consent Form
PLEASE SUBMIT ONE (1) FORM PER STUDENT
Student's Name (Last, First)
Your answer
Student's Birthday (MM/DD/YY)
Your answer
Name of Parent/Guardian 1
Your answer
Telephone (during Shule hours)
Your answer
Name of Parent/Guardian 2
Your answer
Telephone (during Shule hours)
Your answer
Physician Name
Your answer
Telephone (during Shule hours)
Your answer
In case of emergency and neither parent can be reached, the Shule should call:
Emergency Contact 1: NAME
Your answer
Emergency Contact 1: PHONE
Your answer
Emergency Contact 2: NAME
Your answer
Emergency Contact 2: PHONE
Your answer
Emergency Contact 3: NAME
Your answer
Emergency Contact 3: PHONE
Your answer
Any special medical information, medication required, or conditions that may require attention?
Your answer
Any allergies (food, medications, etc.)?
Your answer
Does your child (your family) observe any particular dietary preferences? (e.g., vegetarian)
Your answer
Does your child (your family) observe any particular dietary preferences? (e.g., vegetarian)
Your answer
In case of accident or injury, I give the staff of the Shule permission to authorize medical intervention for my child as they see fit and as deemed necessary by a physician. I understand that they will make every effort to contact me and my child's physician in the event of any medical emergency. I agree to pay for any expenses incurred. I also give permission for the staff to take my child out of the school building for recess and class trips. Sign below.
Signature:
Your answer
Date:
Your answer
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