Student Last Name *

Student First Name *

Student Date of Birth *

Student Gender *

Student Address *

Zip Code *

Student Home Phone *

Father (Guardian) Name *

Father (Guardian) Work Number *

Father (Guardian) Cell Number *

Mother (Guardian) Name *

Mother (Guardian) Work Number *

Mother (Guardian) Cell Number *

Other Emergency Contact Name *

Relation to Student *

Cell/Primary Contact number for "Other Emergency Contact" *

Student's Physician *

Physician's Office Number *

Physician's Exchange or after hours number *

Name of Insurance Company *

Group Number *

Policy Number *

Date of last Tetanus shot *

Does the student have any allergies, special health needs, or require medical care of any type. (Including current medication) *

If "Yes" please explain (If currently on medication, please list - When to take it, how much, and how often)

I/We understand and authorize in the event of an emergency or medical problem, a faculty member, school administrator, or the accompanying chaperone are empowered to make a decision regarding hospitalization and retention of a medical doctor. *

I hereby authorize the emergency treatment, administration of anesthesia and surgical treatment of my minor child, in the event of an emergency medical situation occurring during my absence or when hospital/medical authorities are unable to contact me. I release from responsibility and liability hospital/medical authorities for performing medical procedures deemed necessary during my absence. *

Today's Date *