Emergency Medical

Please PRINT ALL of the information:
Name
FirstLast
Date of Birth*
Grade
Teacher
Allergies:
Medication:
Other problems:
Phone Numbers
Home
Father Work
Father Cell
Mother's Work
Mother Cell
Doctor Name
Doctor Phone
Contact other than parents:(Name, Relationship, Phone)
Contact other than parents:(Name, Relationship, Phone)
Additional information: (Use the back of this paper if needed)
I,_______________________________ , parent of ________________________________ give permission to St. Mary of the Mills School to transport my child via private car or ambulance to the nearest hospital if needed for emergency medical treatment in case of accident or illness while at school or while participating in a school sponsored function. I understand that I will be notified immediately in case of illness, and medical treatment will only be sought if I am not available. I,____________________________ , parent of _________________________ give permission to the nearest hospital emergency room to provide necessary medical evaluation and treatment for my child.
Signature of Parent
Date
Parent Name
FirstLast
Parent Email

Please PRINT ALL of the information: