Form

Consent for Emergency Medical Treatment

2024-2025 School Year
Student Name

First NameLast Name
Roanoke Adventist Christian School and any other authorized employy are hereby authorized to seen emergency care for the student named above should such care become necessary.

Should a medical history be needed, listed below is the physician who shold be contacted. This consent is hereby given for the 2024-2025 school year.
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact: day-time Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Emergency Contact*

First NameLast Name
Alternate Contact: Daytime Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Consent for Emergency Medical Treatment