Emergency Medical Form

Vehicle Emergency Medical Information
Child's Name*
Date of Birth*

MonthDayYear
Date
Address*
Father's Name
Home Phone
Work Phone
Mother's Name
Home Phone
Work Phone
Person to notify in an emergency and parents cannot be reached:
Name
Phone
Child's Doctor
Phone
Phone
Medical facility the center uses 901 18th St, Tifton, GA 31794 Address
Tift Regional Medical Center
Child's Allergies
Current prescribed medication
Child's special needs and conditions
In the event of an emergency involving my child, and if High Hope Academy cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.
Child's Name
Signature (Parent/Guardian)*

Clear
Witness By
High Hope Staff will witness
Date

MonthDayYear
Date
Should be Empty:

Vehicle Emergency Medical Information