Permission for Emergency Care

PERMISSION FOR EMERGENCY CARE

Diocese of Arlington
Appendix F-1

The Following FOrm must be completed
by Parent/Guardian

To be completed and signed annually by a parent/guardian

Name(Required)

First Last

Nickname

First

Sex(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Email for Official School Communication(Required)

Name(s) of any sibling(s) at school(Required)

Student lives with (applicable custody paperwork must be submitted to school)(Required)

Mother/Female Guardian

Father/Male Guardian

both

Mother/Female Guardian First Name(Required)

Mother/Female Guardian Maiden Name(Required)

Mother/Female Guardian Home Address(Required)

Mother/Female Guardian Home City/State/Zip(Required)

Mother/Female Guardian Home Phone(Required)

Mother/Female Guardian Home Email(Required)

Mother/Female Guardian Cell Phone(Required)

Mother/Female Guardian Work Phone(Required)

Mother/Female Guardian Work Email(Required)

Mother/Female Guardian Work Address(Required)

Mother/Female Guardian Occupation(Required)

Mother/Female Guardian Employer(Required)

Mother/Female Guardian Marital Status(Required)

Father/Male Guardian First Name(Required)

Father/Male Guardian Home Address(Required)

Father/Male Guardian Home City/State/Zip(Required)

Father/Male Guardian Home Phone(Required)

Father/Male Guardian Home Email(Required)

Father/Male Guardian Cell Phone(Required)

Father/Male Guardian Work Phone(Required)

Father/Male Guardian Work Email(Required)

Father/Male Guardian Work Address(Required)

Father/Male Guardian Occupation(Required)

Father/Male Guardian Employer(Required)

Father/Male Guardian Marital Status(Required)

Persons NOT authorized to pick up student from school(Required)

Relationship(Required)

Emergency Contact: In the event a parent/guardian cannot be reached, you must give name and contact information for two persons who could collect the student from school in a timely manner. Person #1 name(Required)

Person #1 Address(Required)

Person #1 Phone and Relationship to Student(Required)

Person #2 Name(Required)

Person #2 Address(Required)

Person #2 Phone and Relationship to Student(Required)

Student's Doctor(Required)

Outstanding Medical History(Required)

(e.g. diabetes, heart disease, contact lenses, hearing aids, etc.)

Allergies and action to take(Required)

Student Medications(Required)

Date of Last Tetanus Shot(Required)

Insurance Company(Required)

Policy Number(Required)

I agree to notify the school within 24 hours if my child or any member of their immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize the medical staff to provide treatment, when a physician deems necessary for the well-being of my child. I certify that the information provided in this document is true and accurate to the best of my knowledge(Required)

Printed Name of Parent/Guardian(Required)

Signature of Parent/Guardian(Required)

Date(Required)