Consent for Medical/Emergency Treatment I/we, the undersigned parent(s)/guardian of (student name listed below), a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may so arise, or any hospitalization necessary.Student Name* First Last Parent/Guardian Name* First Last Parent/Guardian Signature*Medical MatterOf the following statements pertaining to medical matters, sign only those in accordance with your wishes: My child is taking medication at present. I will bring all such medications necessary, and such medications will comply with specific requirements on a separate form : “SJHS Medication / Indemnification Form” that has been completed. My child will administer his/her own medication in the office. Parent/Guardian SignatureNo medication of any type may be administered to my child unless the situation is life-threatening and emergency treatment is required. Parent/Guardian SignatureThis consent form will remain in effect until through the last day of school June 2020 for the care and treatment necessary to preserve the health of our/my child. We/I acknowledge that we are/ I am responsible for all reasonable charges in connection with care and treatment rendered during this period. List current medicines your child is taking: Any known allergies? Yes No Explain and identify treatmentAny physical limitations? Yes No Explain Physical LimitationsStudent Emergency InformationStudent info*Click the + icon on the right to add additional childrenFirst NameLast NameGradeDate of birth (mm/dd/yyyy) Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Known allergies Parish/Church/Other Parents Info*First NameLast Name# to receive school messages (emergencies, weather, etc.)Employer / CompanyHome Phone (xxx-xxx-xxxx)Work Phone (xxx-xxx-xxxx)Cell Phone (xxx-xxx-xxxx) Emergency Contact*First NameLast NameRelationshipPhone #
