Student Emergency Information
Which school does your child attend? *
Students Last Name *
Your answer
Students First Name *
Your answer
Students Middle Name
Your answer
Gender *
Mailing Address *
Your answer
City, State and Zip *
Your answer
Check here is you Mailing address is the same as your physical address
Physical Address (if different from your mailing address)
Your answer
City, State and Zip
Your answer
Phone Number
At least one phone number must be provided
Home phone
Your answer
Mother's Cell Phone
Your answer
Father's Cell Phone
Your answer
Birthplace City and State
Your answer
Social Security #
Your answer
That we may be of greatest service to your child in case of accident or sudden illness, it is necessary that you give the following information
Please check legal relation ship to student
First and Last Name
Your answer
Work Phone number
Your answer
Employed by:
Your answer
Work Address
Your answer
Please check legal relation ship to student
First and Last Name
Your answer
Work Phone number
Your answer
Employed by:
Your answer
Work Address
Your answer
IN AN EMERGENCY WHERE NEITHER PARENT CAN BE REACHED, CALL (please include name and number):
Your answer
IN AN EMERGENCY WHERE NEITHER PARENT CAN BE REACHED, CALL (please include name and number):
Your answer
Consent
The school will attempt to reach one of the above persons, but if none of these can be reached the school nurse, principal or teacher in charge, has our permission to use his or her discretion in securing medical aid in an emergency, IT IS UNDERSTOOD THAT NEITHER THE SCHOOL NOR THE PERSON RESPONSIBLE FOR OBTAINING THIS MEDICAL AID WILL BE RESPONSIBLE FOR THE EXPENSE INCURRED. This authorization does not cover surgery. In such cases, the provisions of Colorado Law governing informed consent and such other authorization(s) as may be required by law, shall apply.

Facts concerning the child's medical history including: allergies, medications, and any physical impairments to which a physician should be alerted are as noted on the Health Information Form

In the event reasonable attempts to contact me or the emergency contacts at the above listed phone numbers have been unsuccessful, I hereby give my consent for:
The transfer for the child to a preferred hospital or any hospital reasonably accessible. Please list your preferred hospital:
Your answer
Do you have ambulance insurance?
With whom?
Your answer
Student Insurance
The school has the moral responsibility to encourage each participant in athletics to be covered by an accident insurance policy. The school does not provide a policy; however the school provides an insurance option in which students may voluntarily participate. If you decide to take the school insurance option, the policy must be paid for before practice begins for that sport.
If you decide to take the school insurance option, the policy must be paid for before practice begins for that sport.
The insurance company I will use is:
Your answer
Electronic Signature - Please type your first and last name
Your answer
I understand that checking this box constitutes a legal signature confirming that I acknowledge that the above information is correct
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