Burleson Adventist® School

Giving

Emergency & Medical Form

Emergency & Medical Form

This field is for validation purposes and should be left unchanged.

Student Information

Student Name*
Date of Birth*
Please enter a number greater than or equal to 1.
Is your student covered by health insurance?

Parent Information

Parent/Guardian 1*
Parent/Guardian 2*

Medical Permission

In case of emergency, accident, or serious illness, if the school is unable to contact me, I hereby authorize the school to take my child to the physician, emergency room, and/or to the relative or family friend indicated.
Medication to be taken at school requires a completed Medical Permission Form.
OTC Medication*
Permission is granted for designated school personal to administer OVER THE COUNTER medication to my child, if needed, as listed:
OTC Medication admin MAY administer:
All dosages will be according to age/weight of the child as listed on the medication.

Emergency Contact

List the names of two relatives or friends who have consented to assume the responsibility of your child in case of illness or accident until you can be reached. In case of any change in the named person, notify the school in writing.
Emergency Contact 1*
Emergency Contact 2*
Consent*
Parent/Guardian Name*