Emergency Medical Consent

ALL IN ONE MEDICAL & PICK UP FORM

This form must be completed prior to your child starting each instructional year. You must give us consent to get medical treatment for your child, pick up your child if you are unavailable and let us know about any and all medical issues including food allergies/intolerances/religious observation of food laws. This form must be completed for each child enrolled.
Student's Name*

First NameLast Name
Student's date of birth*

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

First NameLast Name
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, any issue that our staff needs to be aware of. 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:
Student's Name (skip down to complete parent/guardian area if you only have one student enrolled in our academic programs)

First NameLast Name
Student's date of birth

MonthDayYear
Date
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 see our policies and precedures that you have electronically signed for more information on this.)
Student's Name

First NameLast Name
Student's date of birth

MonthDayYear
Date
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 see our policies and precedures that you have electronically signed for more information on this.)
Student's Name

First NameLast Name
Student's date of birth

MonthDayYear
Date
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 see our policies and precedures that you have electronically signed for more information on this.)
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 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 (if none, please type 'Not Applicable'):*
OASN has my permission to obtain emergency medical treatment for my child: blanks* field. when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is at 7634 SW 60th Avenue, Ocala, FL 34476 (onsite, at the playground or any area around or building). Furthermore, I will hold harmless OASN (Outreach Autism Services Nettwork), & it's subsidiary company, Ocala Preparatory Academy, the OASN board, the OASN staff members, and Heritage Management.*

I agree
Name of Parent or Guardian giving permission to obtain medical treatment signing in agreement to all stated above. *

First NameLast Name
Please list name of person authorized to pick up your student(s) in the event of an emergency (if allowed for other reasons, please list this person again in the area below)*

First NameLast Name
Phone Number of Authorized Emergency Pick Up Person*

Area CodePhone Number
Please use this area to add any additional person authorized to pick up your child. Also, please notate if this is for emergency situations only or if this is for regular pick up of your child. If you do not have anyone else that is authorized to pick up your child (we must have at least one person to contact in an emergency), please explain this below.*
Parent/Legal Guardian Signature*

Clear
if using touch screen use finger or stylus to sign
Should be Empty:

ALL IN ONE MEDICAL & PICK UP FORM