Emergency Medical Consent

REQUIRED REGISTRATION FORM (new & returning students)

This form must be completed prior to your child starting school each instructional year. You must give us consent to get medical treatment for your child and provide all information on this form. If you are a returning student, our education coordinator will let you know what documents are required for re enrollment. This form must be completed for each child you are enrolling or reenrolling for each Instructional Year. Thank you.
Student Full Legal Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth*
Student Race:*

White-HispanicBlack/African American-HispanicWhite-Non HispanicBlack/African American-Non HispanicAsian Indian or Alaska NativeNative Hawaiian Pacific Islander
Student sex at birth:*

MaleFemale
Student date of birth*

MonthDayYear
Date
Parent/Guardian 1 (completing this form)*

First NameLast Name
Parent/Guardian #1 Occupation*
Parent/Guardian 1 Email*
example@example.com
Allergies/Intolerances/Religious Observation of Food Laws (if you do not provide this information, there is no way we can be aware of this information in the event of an emergency or daily onsite. Please initial that you understand this. *
If your child has allergies/intolerances/religious observation of food laws-please list this information in detail:
We need to be aware of all medical diagnoses or any issue that may be important to assist your child medically, or otherwise. If you do not provide this information, there is no way we can be aware of this information in the event of an emergency or daily onsite. Please initial that you understand this:*
If your child has any medical diagnoses, any issue our staff needs to be aware of-please list this information in detail:
Parent/Guardian 1 Primary Phone*

Area CodePhone Number
Parent/Guardian 1 Alternate Phone

Area CodePhone Number
Parent/Guardian 2

First NameLast Name
Parent/Guardian 2 Occupation
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Primary Phone

Area CodePhone Number
Parent/Guardian 2 Alternate Number

Area CodePhone Number
My child(ren)'s insurance provider is:*
My child(ren)'s insurance number is:*
Preferred Hospital treatment center
My child is taking the following medications AT HOME (if none, please type 'Not Applicable'):*
My child will have the following medications dispensed AT SCHOOL (if none, please type 'Not Applicable' or that dispensing would be done only as a backup, as needed or PRN):*
Please upload documents required for enrollment/re enrollment of my child. This is a list of items that are required for new students: Child's Birth Certificate, Child Social Security Card, Parent ID: State Issued, Military Issued, or Passport, Religious Exemption Form or Immunization Form, Physical Form, Medical Insurance Card, IEP, 504. etc.)

Browse Files

Cancelof
OASN/Ocala Preparatory Academy has my permission to obtain emergency medical treatment (at my cost or billed to my insurance) for my child: blanks* field. when I cannot be reached or if a delay in coming to pick up my child would be dangerous for him/her.
Name of Parent or Guardian giving permission to obtain medical treatment (at my cost) signing in agreement to all stated above. *

First NameLast Name
Signature of Parent/Guardian authorizing OASN/Ocala Preparatory Academy to obtain medical treatment at my cost or billed to my insurance for the above listed child when I cannot be reached or if a delay in coming to pick up my child would be dangerous for him/her.*

Powered by Jotform SignClear
Should be Empty:

REQUIRED REGISTRATION FORM (new & returning students)