School __________________  Grade __________ Student's Name _______________________________

Street Address ___________________________ City, State & Zip _______________________________

Telephone Number (with area code) _________________________ Birthdate ______________________

Purpose - - To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Residential Parent or Guardian

Mother's First & Last Name _____________________________________________________________

Mother's Daytime Phone (with area code)____________________________________________________

Father's First & Last Name ______________________________________________________________

Father's Daytime Phone (with area code) ____________________________________________________

Other Contact Person's First & Last Name __________________________________________________

Other Contact Person's Daytime Phone (with area code) ________________________________________
 

Name of Relative or Childcare Provider

_____________________________________________ Relationship to Child ______________________

Street Address _________________________________ City, State & Zip _________________________

Daytime Phone Number (with area code) ____________________________________________________