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Student Name______________________________________________________________________

Date of Birth_________________ Phone: Home (_____)________________________ Sex (circle) Male Female

Parents/Guardians________________________________________ Email:_________________________________

Home Address______________________________________________________________________

Work Mom (____)____________________ Work Dad (____)_______________________

Cell Mom (____)______________________ Cell Dad(____)_________________________

Emergency Contact Name__________________________________ Phone (____)_________________

Medical Insurance Company__________________________________________________________

Policy #________________________________ ID#____________________________________

Doctor’s Name_______________________________ Phone (____)________________________

Dentist’s Name_______________________________ Phone (____)________________________


I, _________________________________, being the parent or legal guardian of _________________________, give my consent for emergency medical and surgical treatment in a licensed medical facility by a licensed physician should my child’s condition require it in my absence. I understand that in such a case, reasonable attempts would first be made to contact me, time, and conditions permitting. SkyView Academy does not have any medical/dental/hospitalization insurance covering students for injuries incurred at school, including after school activities. If you have not already done so you should investigate and must obtain medical insurance coverage for your child.

As long as the medical or surgical treatment considered necessary in the situation is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific prohibitions regarding treatment unless stated here:_____________________________________________________

My student has the following medical conditions, which may require emergency care (include allergies):


I confirm to SkyView Academy that my child is in good health and that his/her participation does not pose a hazard to his/her health or that of participating students.  If my child has any medical conditions that require medication, I acknowledge that my child is capable of administering his/her own medication as SkyView Academy does not have any medical staff on site during after school activities. In the event of a medical emergency, 911 will be called to provide treatment and transport, if necessary. By signing below, I release and waive any and all claims which I now have or may hereafter have against SkyView Academy and its employees pertaining to any injuries and/or medical emergencies that may occur while my child is participating in an after school activity.

Signature of Parent/Guardian_______________________________________________Date___________________________

WD Forms                                                                                                                                      8/17