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Consent for Medical/Emergency Treatment

Please complete the form below. Required fields marked with an asterisk *

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*

Answer required for " First"

Last*

Answer required for "Last"

Parent/Guardian Name

First*

Answer required for " First"

Last*

Answer required for "Last"

Medical Matter

Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:

Answer required for "Of 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.

No medication of any type may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Option

Parent/Guardian Signature*

Signature Required

This consent form will remain in effect until through the last day of school June 2026 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:

Answer required for "List current medicines your child is taking:"

Any known allergies?*

Answer required for "Any known allergies?"

Yes

Any physical limitations?*

Answer required for "Any physical limitations?"

Yes

Student Emergency Information

Student info

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of birth (mm/dd/yyyy)*

Answer required for "Date of birth (mm/dd/yyyy)"

Grade*

Answer required for "Grade"

Home Address

Street Address*

Answer required for "Street Address"

Address Line 2

Answer required for "Address Line 2"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Known allergies

Answer required for "Known allergies"

Parent/Guardian Info

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

# to receive school messages  (emergencies, weather, etc.)

Number Required

Employer / Company

Answer required for "Employer / Company"

Home Phone

Number Required

Work Phone

Number Required

Cell Phone

Number Required

Emergency Contact

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Relationship*

Answer required for "Relationship"

Phone #*

Number Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"