Parent/Guardian *
Parent/Guardian
Daytime Phone *
Daytime Phone
Address *
Address
Child's Physician *
Child's Physician
Phone *
Phone
Is the student currently taking any medications? *
Does this student have any allergies? *
Consent to treat *
In the event that my child becomes ill or is injured while under school supervision, I approve the school authorities taking the following steps in the following order: 1. Contact a parent or legal guardian of the student and follow his or her instructions. 2. In the event of an emergency, when neither parent nor legal guardian can be reached, the school authorities are hereby authorized to use their best judgment in contacting a properly licensed physician, or in transporting my child to the nearest hospital for consultation and/or treatment. It is understood that reasonable effort will be made to contact the doctor listed above before any other physician is called by the school or other organization. Transportation is to be done either by school-provided transportation, or if school officials deem it wise, by ambulance. If, in the opinion of a properly licensed and practicing physician, my child needs medical or surgical services which require my consent before being supplied, and I cannot be reached, I hereby authorize, appoint, or empower the Principal or his designated representative, to furnish on my behalf such written or oral authorization as may be so required. Furthermore, I release the Principal, or his designated representative, and Shoal Creek Adventist School from any liability which might arise from the giving of such authorization, it being my desire that my child be furnished with such medical or surgical services as soon as possible after the need arises.
Parent/Guardian *
Parent/Guardian
Date
Date