Student Emergency Information Page 2

Physician to be notified______________________________________ Phone

_________________________

Address

__________________________________________________________________________________

D e n t i s t t o b e n o t i f i e d _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone__________________________

Address______________________________________________________________________________

____

● In the event of an accident or serious illness, if a parent/guardian or emergency contacts

cannot be reached, I authorize the school to call a doctor and/or arrange for transport and

appropriate medical/emergency room care at the nearest hospital facility.

Parent/Guardian Signature___________________________________________ Date_____/______/

_______

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Parent category: Business