Student Emergency Medical Form

ADVERTISEMENT

Westfield, New Jersey 07090
(
)
STUDENT EMERGENCY MEDICAL FORM
STUDENT’S NAME:
STUDENT’S BIRTHDAY :
GRADE:
STUDENT’S STATE ID:
HOME PHONE NO:
LEGAL RESIDENCE:
CITY:
ZIP:
Parent/Guardian Information:
Parents in same household as student: Guardian 1 is mother, Guardian 2 is father.
Parents in separate households: Guardian 1 is custodial parent, Guardian 3 is non-custodial parent.
(Guardian 1 must have the same Westfield home address as student)
GUARDIAN 1 ( Relationship:
)
GUARDIAN 2 ( Relationship:
)
GUARDIAN 3 ( Relationship:
)
NAME:
NAME:
NAME:
HOME PHONE NO:
HOME PHONE NO:
HOME PHONE NO:
WORK PHONE NO:
WORK PHONE NO:
WORK PHONE NO:
CELL PHONE NO:
CELL PHONE NO:
CELL PHONE NO:
E-MAIL:
E-MAIL:
E-MAIL:
HOME ADDRESS (non-custodial parent) :
CITY:
ZIP:
IN MY/OUR ABSENCE, THE FOLLOWING (RELATIVE, NEIGHBOR, FRIEND OR CARETAKER) IS AUTHORIZED TO ACT FOR ME/US IN BEHALF
OF MY/OUR CHILD. (PLEASE BE SURE THE FOLLOWING PEOPLE HAVE CONSENTED TO ACT IN YOUR BEHALF)
NAME:
ADDRESS:
PHONE NO:
NAME:
ADDRESS:
PHONE NO:
NAME:
ADDRESS:
PHONE NO:
IF MY/OUR CHILD REQUIRES IMMEDIATE MEDICAL ATTENTION BECAUSE OF ILLNESS OR AN ACCIDENT AND I CANNOT BE REACHED BY
TELEPHONE, I AUTHORIZE THE SCHOOL TO SUMMON MEDICAL ASSISTANCE AT MY EXPENSE. PLEASE CALL:
PHYSICIAN’S NAME:
PHONE NO:
DENTIST’S NAME:
PHONE NO:
HOSPITAL INFORMATION:
PHONE NO:
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2