May 2011 Dear Parents: It is hard to believe that this school year is ...

EMERGENCY CARE AUTHORIZATION
Account #________________
Name _________________________________________________________________ Home Phone _________________________
Last Father Mother
Address ____________________________________________________________________________________________________
Street City ZIP
Email address:___________________________________________________________
Student’s Name
Birthdate
Mo/Day/Year
Sex
M/F
Grade
2011-2012
If any of my children become ill or are injured at school, please notify me.
Father‟s place of employment: ______________________________________________ Phone # ___________________________
Cell Phone # _______________________
Mother‟s place of employment: _____________________________________________ Phone # ___________________________
The following friends or relatives may also be contacted:
Cell Phone # _______________________
_____________________________________________________________________Phone # ___________________________
_____________________________________________________________________Phone # ___________________________
If I cannot be contacted, my child may be taken to Dr. ____________________________ Phone # ___________________________
or to ______________________________________ Hospital, or to any other physician who is available.
Please list any medications your child(ren) takes on a daily basis at home or school. This is needed in case emergency treatment is necessary. It is also
necessary to know if your child has health concerns which may limit their participation in physical education classes. Some examples: asthma, allergies, heart
problems, vision, etc. It is the parent‟s responsibility to inform the physical education instructors if there are limitations. Please fill in the information below:
Student Name Medication Dosage Limitations
My child(ren) named above have my permission to receive non-aspirin or other pain reliever from the office _________________
(Parent‟s initials)
The Principal of Hudsonville Christian School is hereby authorized to follow the plan outlined above in the handling of emergency care of my children. I
agree to pay all expenses incurred by the handling of this emergency care.
______________________________________________________ _________________________
DRAFT 05/04/11