24-25 Health Room ICA Green

Emergency contacts (other than parents) must be local and available for contact:
1) Contact Name and Relationship to child*
1) Contact Phone Number*
Please enter a valid phone number.
2) Contact Name and Relationship to child
2) Contact Phone Number
Please enter a valid phone number.
Dentist's Name & Address*
Dentist's Phone Number*
Doctor's Name & Address *
Doctor's Phone Number*
Medical Insurance
CHIP
Private
Insurance Company Name*
Policy #*

Your signature gives permission for emergency treatment; as well as for School Authorities to administer medications you indicate on this emergency form, during school hours, on field trips, and after school activities. I authorize the school to communicate with my child's health care provider and my health care provider to reply as needed regarding my child's care.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Type a question

Type option 1Type option 2Type option 3Type option 4