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Oldenburg Academy Contact Information
Emergency Medical Form
This information is required each year to aid Oldenburg Academy faculty and staff in complying with the changing requirements of health insurance policies as well as giving parental consent for the treatment of injuries. A copy of this form is taken on all school field trips. All students are required to complete this form.
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Allergies/Medical Conditions *
Your answer
Address *
Your answer
City, State & Zip *
Your answer
Residing County *
Your answer
Home Phone Number *
Your answer
Emergency Contact Name #1 *
Your answer
Emergency Contact Number #1 *
Your answer
Emergency Contact Name #2 *
Your answer
Emergency Contact Number #2 *
Your answer
With whom does the student live *
Required
Father/Guardian *
Your answer
Address *
Your answer
City, State & Zip *
Your answer
Cell Phone *
Your answer
Father's email (type NA if none) *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Mother/Guardian *
Your answer
Address (if different than above)
Your answer
City, State & Zip
Your answer
Cell Phone *
Your answer
Mother's email (type NA if none) *
Your answer
Home Phone (if different than above)
Your answer
Work Phone
Your answer
Does the student have health insurance *
Primary Insurance Company *
Your answer
Parent/Guardian Name on Insurance Card *
Your answer
Group Number *
Your answer
Policy Number *
Your answer
Phone Number for Insurance *
Your answer
Family Physician Name *
Your answer
Physician Phone Number
Your answer
I hereby authorize Oldenburg Academy faculty and staff any emergency medical treatment of my son/daughter should they become injured. Included in this consent is permission to transport and treat in route to a medical facility should the injury be deemed serious in nature. I also provide consent to the medical facility to perform any necessary procedures if I cannot be reached, and I understand that I am responsible for any payments to said medical facility if treatment is not covered by insurance. *
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