Emergency Medical Information and Treatment Form


Student Name

Address

Age


Grade level



Parent(s)/Legal Guardian


Address


Home phone


Business phone

Cell phone


In case of emergency, and parent/legal guardian cannot be reached, contact:


Name


Phone


Name


Phone

I hereby authorize emergency medical treatment for my son/daughter in the event of accident or illness while attending class, activity, event, or program sponsored by Oak Meadow School.


This authorization shall begin

and end


                                                                                                        

Signature of Parent/Legal Guardian

Dated


Allergies of any kind (medications, etc.)