Emergency Information Form (Page 2 of 3) in pdf

Emergency Information Form Page 2

REFUSAL OF CONSENT:

I DO NOT GIVE CONSENT FOR EMERGENCY MEDICAL TREATMENT OF MY CHILD. IN THE EVENT OF

ILLNESS OR INJURY REQUIRING TREATMENT, I WISH THE SCHOOL TO TAKE NO ACTION OR TO:

_____________________________________________________________________________

_____________________________________________________________________________________________

______________________________________________

Date Parent/Guardian Signature

MEDICAL INFORMATION

It is the sole responsibility of the Parent/Guardian to provide accurate medical information and updates in

writing. PLEASE

PROVIDE CLEAR AND LEGIBLE INFORMATION concerning the following, if applicable: Health, allergies,

medication.

_____________________________________________________________________________________________

Copy of front and back of insurance card (s)

Emergency Information Form Page 2