Student Emergency Form
ADVERTISEMENT
1Kennewick School District 17
F-2 2320
STUDENT EMERGENCY INFORMATION
MEDICAL PERMISSION - INSURANCE AUTHORIZATION - TRAVEL PERMISSION
Student Name _______________________________________ School___________________ Grade ___________
Student Birth Date ____________________________
Activity __________________________________
Student Address____________________________________________ City____________________ Zip __________
EMERGENCY MEDICAL TREATMENT AND INSURANCE AUTHORIZATION
As the parent/guardian of the above named student, my signature on this form authorizes any emergency medical treatment by a licensed
medical physician and/or medical facility in the event of accident, illness or injury.
Does the supervising person have your permission to seek medical attention from the nearest licensed physician and/or medical
facility?
Yes, parent/guardian initial ______
No, parent/guardian initial ______ Please specify below the procedure you wish the supervising person to follow:
I am aware that Kennewick School District does not provide medical insurance coverage for accidents/injuries resulting from
participation in school and/or school-related activities. As the parent/guardian of the above named student, I accept full responsibility for
the cost of treatment for any accident, illness or injury which my student may suffer while participating in school/school related activities.
I understand that my student must maintain adequate medical insurance coverage in order to participate in interscholastic
athletics/activities, and that it must be kept in force throughout the sport/activity season.
HEALTH ALERTS -
Parents must note any medical conditions below
□ Voluntary School Medical Insurance Protection
Date of last Tetanus booster: _________________________
□ Medical Coupons
Medication Allergies: ________________________________
□ Family Medical Insurance
Other Allergies:
________________________________
MEDICAL CONDITIONS:
CURRENT MEDICATIONS:
Family Physician_____________________________________________________ Telephone___________________
Kennewick Trios
Richland Kadlec
Pasco Our Lady of Lourdes
Preferred Hospital:
Telephone number where each parent/guardian can be contacted:
Father/Guardian_____________________________ Home ___________________ Work _______________ Cell ______________
Mother/Guardian____________________________ Home ___________________ Work _______________ Cell ______________
Emergency Contact:
Name_____________________________________ Relationship_____________ Phone______________________
Alt. Phone ______________________
Name_____________________________________ Relationship_____________ Phone______________________
Alt. Phone ______________________
STUDENT TRAVEL PERMISSION
Kennewick School District has my permission to transport my son/daughter by District Bus/Vehicle, Private Vehicle and/or Rental
Vehicle.
________________________________________________________
____________________
(Signature of Parent/Guardian)
(Date)
June 2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business