Emergency Medical Authorization Form

Child’s Name *

Birthday *

Age *

Sex

Male

Female

My child has a medical condition and/or allergies that require medication and a physicians attention:

No Yes

Please list below all allergies or medical conditon of which we should be aware: (additional forms will be required)

Please list any medications currently being taken by the student:

Emergency Contacts

In the event of an emergency, please indicate phone numbers where parents/guardians or relatives can be reached:

Adult

Name: *

Relationship: *

Home or Cell Phone: *

Work Phone:

Add Remove

Emergency Care

In the event of an emergency, I authorize the staff of St. James Preschool to provide any first-aid care deemed necessary for my child. I also, hereby authorize any needed emergency medical care. I further agree to be fully responsible for all expenses incurred during the treatment of my child.

The medical facility that St. James Preschool will use is: Piedmont Henry Hospital in Stockbridge.

Medical Insurance Carrier: *

Subscribers Names: *

Policy Number: *

Child’s Physician: *

Phone *

Child’s Dentists: *

Phone *

Signature *

Date *

If you are human, leave this field blank.