WCCC Emergency Medical Authorization
To enable parents/guardians to authorize the provision of emergency treatment for students who become ill or injured while under school authority when parents or guardians cannot be reached.
Career Technical Lab *
Grade *
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth
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Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Home Phone *
Please include the area code. If not applicable, please type "N/A"
Your answer
Father's Name *
If not applicable, please type "N/A"
Your answer
Father's Daytime Phone Number *
Please include the area code. If not applicable, please type "N/A"
Your answer
Mother's Name *
If not applicable, please type "N/A"
Your answer
Mother's Daytime Phone Number *
Please include the area code. If not applicable, please type "N/A"
Your answer
Legal Guardian *
Please type first and last name. If not applicable, please type "N/A"
Your answer
Legal Guardian's Phone Number *
Please include the area code. If not applicable, please type "N/A"
Your answer
Parent/Guardian Email Address *
If not applicable, please type "N/A"
Your answer
Student Resides With *
Custodial Parent *
EMERGENCY CONTACTS
Emergency Contact #1 *
In case of an emergency and neither parent can be reached, the school should contact (please list the names of LOCAL persons that can contact you in the event of an emergency or illness).
Your answer
Relationship to Student #1 *
Your answer
Daytime Phone #1 *
Your answer
Permission to Pick up Student #1 *
Emergency Contact #2 *
In case of an emergency and neither parent can be reached, the school should contact (please list the names of LOCAL persons that can contact you in the event of an emergency or illness).
Your answer
Relationship to Student #2 *
Your answer
Daytime Phone #2 *
Your answer
Permission to Pick up student #2 *
Emergency Contact #3
If not applicable, please type "N/A"
Your answer
Relationship to Student #3
If not applicable, please type "N/A"
Your answer
Daytime Phone #3
If not applicable, please type "N/A"
Your answer
Permission to Pick up Student #3
If not applicable, please type "N/A"
Student Medical Facts
Facts concerning the student's medical history, including allergies, medications begin taken and any physical impairment to which WCCC or a physician should be alerted.
List all medical conditions *
If not applicable, please type "N/A"
Your answer
List all medicines taken daily *
If not applicable, please type "N/A"
Your answer
List all medicine allergies *
If not applicable, please type "N/A"
Your answer
List all food and environmental allergies *
If not applicable, please type "N/A"
Your answer
Treatment for the above allergies *
If not applicable, please type "N/A"
Your answer
Does the student wear contacts or glasses? *
List all vision and/or hearing problems *
If not applicable, please type "N/A"
Your answer
Date of Current Tetanus Immunization *
We request that tetanus be current. If not applicable, please type "N/A".
Your answer
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.
Part 1 or Part 2 - *
Please choose one.
PART 2 - Action *
If you chose PART 2 above, please list the actions below that you would like for WCCC to follow. If not applicable, please type "N/A".
Your answer
Comments or concerns about the student's health of which the school should be aware *
If not applicable, please type "N/A"
Your answer
List all medical facts regarding the student *
Facts concerning the student's medical history, including allergies, medications being taken and any physical impairment to which a physician should be alerted
Your answer
Physician Name *
Your answer
Physician Phone Number *
Your answer
Dentist Name *
Your answer
Dentist Phone Number *
Your answer
Specialist Name
If not applicable, please type "N/A"
Your answer
Specialist Phone Number
If not applicable, please type "N/A"
Your answer
Preferred Hospital *
Your answer
FIELD TRIP PERMISSION
FIELD TRIP PERMISSION (parent initials) *
I give my student permission to attend all field trips associated with Warren County Career Center for this school year. This includes field trips with classes, bus trips, extracurricular trips, etc. I understand most trips are taken on district owned vehicles driven by Petermann Bus Services. ALL SCHOOL RULES AND POLICIES ARE IN EFFECT ON EVERY FIELD TRIP. By typing my initials, I grant permission for my child to be transported by a school bus or other district owned vehicle driven by Petermann Bus Services. I also agree with all the above field trip information and I understand that the Board of Education, the School Administrators, advisors, teachers, etc. assumes no liability for the trip(s).
Your answer
I understand that by typing my name below, I deem that all information is correct and that I am electronically signing this document.
Parent/Guardian Signature *
Your answer
Parent Address, City, Zip *
Your answer
Date *
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