EMERGENCY MEDICAL TREATMENT FORM 2024

EMERGENCY MEDICAL TREATMENT FORM 2024
Upload a Current Student Photo OR Attach Picture to this printed form.

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Student Name*

First NameMiddle NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
PARENT/LEGAL GUARDIAN INFORMATION:
Mother/Guardian*

First NameLast Name
Mother/Guardian Work Phone
Please enter a valid phone number.
Mother/Guardian Cell Phone *
Please enter a valid phone number.
Father/Guardian

First NameLast Name
Father/Guardian Work Phone
Please enter a valid phone number.
Father/Guardian Cell Phone
Please enter a valid phone number.
IF PARENTS/GUARDIANS CANNOT BE CONTACTED, PLEASE CONTACT:
EMERGENCY CONTACT (OTHER THAN PARENTS/GUARDIANS)*

First NameLast Name
Relationship of Emergency Contact to Student*
Emergency Contact Cell Phone*
Please enter a valid phone number.
Emergency Contact Home Phone *
Please enter a valid phone number.
Address of Emergency Contact*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the student have health insurance?*

YesNo
INSURANCE INFORMATION

(Blue Cross, PPO, HMO, Other)
Image of FRONT of Insurance Card OR Attach image to this form

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Image of BACK of Insurance Card OR Attach image to this form

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Policy Holder's Name:*

First NameLast Name
Insurance Company*
Group No.*
Contract #*
Service Code
Policy Holder's Employer*
MEDICAL INFORMATION
Date of Last Tetnus Shot:
Primary Care Physician*
Physician Phone*
Please enter a valid phone number.
Does the student have any special dietary needs?*
Special Dietary Needs: (ie. gluten intolerance, lactose intolerance, etc.)
Food Allergies?
If you answered "Yes" to food allergies, please list the allergies here:
Medical/Medicine Allergies?*
If you answered "Yes" to Medical/Medicine Allergies, please list the allergies here:
Medical condition or medical history that should be known to medical staff:
Diabetic?*
If yes, please answer the following questions...
How often is blood sugar monitored?
List insulin:
IMPORTANT: THIS SECTION MUST BE COMPLETED IN THE PRESENCE OF A NOTARY REPUBLIC. DO NOT SIGN THIS FORM AHEAD OF TIME. PRINT AND BRING WITH YOU TO REGISTRATION.
MEDICAL TREATMENT/DISCIPLIANARY RELASE:
If the parents and authorized physician named cannot be reached at the time of an emergency and if immediate observation or treatment is urgent in the perception of school authorities, I authorize that my son/daughter be take to the hospital for emergency medical treatment.

Notary Republic: place seal in space above.

Parent Signature: __________________________________
Date: ____________________________________________

Notary Public Signature: _____________________________
Date: ____________________________________________
Should be Empty:

EMERGENCY MEDICAL TREATMENT FORM 2024

PARENT/LEGAL GUARDIAN INFORMATION:

IF PARENTS/GUARDIANS CANNOT BE CONTACTED, PLEASE CONTACT:

INSURANCE INFORMATION

MEDICAL INFORMATION

IMPORTANT: THIS SECTION MUST BE COMPLETED IN THE PRESENCE OF A NOTARY REPUBLIC. DO NOT SIGN THIS FORM AHEAD OF TIME. PRINT AND BRING WITH YOU TO REGISTRATION.