________________ School Music
Emergency Medical Information
Student’s Name:_______________________________________YOG:___________
Address______________________________________________________________
Parent(s)’Guardian(s) Name(s)____________________________________________
Parent/Guardian Email(s)_______________________ _________________________
Phone Number during the day____________________ night____________________
Cell Phone Numbers___________________________ ________________________
Does the student take any medications? ____________________________________
If yes, what medication and how often? _____________________________________
Can the student oversee their own medication?_______________________________
Does the student have a medical condition we should be aware of? _______________
OPTIONAL: Medical Coverage Company: ___________ Policy #: ____________
I, ________________________________________, parent or legal guardian of the child named above, and legally entitled to give this authorization, give Mr/Ms ____ and members of the teaching/chaperone staff the power to authorize medical treatment to my child in the event of an emergency situation.
Signature__________________________________________ Date_________________
This form will be kept secure to protect privacy.
