Consent to Treat

Only designated staff will have access to the completed form. This form must be filled out at the beginning of each school year to cover the activities for the school year. A copy of each student’s form must be taken on off-campus activities.

Consent to Treat

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

Date*

Student's full name*

First Last

Age*

Date of Birth*

Social Security Number

Parent/Guardian Information

Father/Guardian Name

First Last

Work Number

Home Number

Cell Number

Social Security Number

Mother/Guardian Name

First Last

Work Number

Home Number

Cell Number

Social Security Number

Section

Please describe allergies to substances and medications*

If on regular medication, please specify*

Date of Last Tetanus Shot*

Please give the name of your local family physician to be called in case your child becomes ill or has an accident at school and you cannot be reached*

Physician's Office Address*

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

Physician's Office Number*

Please give the name of a relative or friend who has consented to assume the responsibility of your child in case of illness or accident until you can be reached. In case of any changes in the named person, notify the school in writing. *

Number of Realtive/Friend*

Address of Realtive/Friend*

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

The above named student is/is not covered by health insurance*

Present Health Insurance Company*

Policy Number*

If emergency service involving medical action or treatment is required and neither the parent nor the family physician can be reached for consent, the parents hereby consent to the rendering of such emergency medical service for the above named student as shall be necessary in the medical opinion of the doctor rendering service. *

Date*