Transportation/Emergency Care Authorization Form

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Sport *

Level (Varsity, JV, Modified) *

Student Name (Last Name, First Name) *

Date of Birth *

YYYY

Address (include city, state, and zip code) *

Phone Number (include area code) *

Parent Email Address *

Allergy to any medication: Yes/No; If yes, please list. *

This document shall be presented to a physician, dentist, or appropriate hospital representative at such time as emergency medical, dental, surgical or hospitalization may be required. I/We being the parent(s) or guardian(s) of the above named student do hereby allow my child to be transported by Southern Cayuga Central School. I/We allow a qualified medical person to act in my/our behalf in authorizing medical, dental, surgical, care and hospitalization for the above named student in the event I/We cannot be reached. *

By checking here I acknowledge and agree to authorization as stated above.

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