Student Emergency and Medical Record Form

Email:(for contact purposes) *
Student's Name: * First Last
Emergency Contacts:

Please list three people we may contact in case of emergency and to whom the student may be released if unable to contact the parents.
Name of Contact: * Title First Last Suffix
Relationship: *
Cell Phone: * ### - ### - ####
Work Phone: * ### - ### - ####
Name of Contact: Title First Last Suffix
Relationship:
Cell Phone: ### - ### - ####
Work Phone: ### - ### - ####
Name of Contact: Title First Last Suffix
Relationship:
Cell Phone: ### - ### - ####
Work Phone: ### - ### - ####
DOCTOR INFORMATION:
Name of Doctor: *
Medical Facility: *
Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number: * ### - ### - ####
HEALTH INFORMATION

Please check all boxes that apply.
Asthma - Mild to Moderate Asthma - Severe Attention Deficit Disorder Attention Deficit with Hyperactivity Blood Disorder Cancer Cerebral Palsy Chicken Pox Chronic Fatigue Syndrome Cystic Fibrosis Diabetes Dental Problems Earaches - Frequent Eating Disorder Emotional/Psychological Disorder Genetic Disorder Hearing Problems-Aids Hearing Problems-Deaf Hearing Problems - Tubes in Ears Heart Problems - No restrictions Heart Problems - Restrictions Hemophilia Hypoglycemia Kidney/Urinary Tract Measles Migraine Headaches Mumps Muscular Dystrophy Neurological Disorder Nosebleeds Rubella Skin Condition Tuberculosis
Does your child have a allergies? If yes, please explain:
What medication(s) is your child currently taking:
MEDICATION NOTE:

Please note that all medication, including over the counter and prescribed, given during the school day must have a Request for Adminstration of Medication form (or the equivalent) completed and signed by the physican and parents. Students are not allowed to carry medications including Tylenol, aspirin, Motrin, etc. during the school day. Exceptions are contingent upon written physician approval. Please see to it that your child understands this policy.
Does you child have frequent colds:
Does your child wear glasses? If yes, give reason:
Does your child have any illness or disorder that require special attention? Explain:
Are there any special procedures we should follow in case of an emergency with your child:
PARENTAL AUTHORIZATION TO CONSENT TREATMENT OF MINOR FOR ACTIVITIES ON OR OFF THE SCHOOL GROUNDS

Terms (check each box)
I/We the undersigned consent to have my/our child participate in field trips supervised by the teaching staff, away from school grounds.
I/We Agree
I/We do authorize the ROCK Academy as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, as is to be rendered under the general or special supervision of, any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital
I/We Agree
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment and hospital care which the aformentioned physician in the exercise of his/her best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
I/We Agree
I/We hereby authorize any hospital that has provided treatment to the above-named minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to (my/our) above name agent(s) upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California.
I/We Agree
These authorizations shall remain in effect for the duration of enrollment at this school, unless sooner revoked in writing delivered to said agent(s).
I/We Agree
Please take a moment and double check you answers befor pressing the submit button.
Do Not Fill This Out

Wufoo

Emergency Contacts:

DOCTOR INFORMATION:

HEALTH INFORMATION

MEDICATION NOTE:

PARENTAL AUTHORIZATION TO CONSENT TREATMENT OF MINOR FOR ACTIVITIES ON OR OFF THE SCHOOL GROUNDS