Parental Consent for Student Medical Treatment

Student Information

Student Name Date of Birth School Name Grade/Year

Parent/Guardian Information

Parent/Guardian Name Relationship to Student Phone Number Email Address Address

Medical Information

Allergies Current Medications Relevant Medical Conditions Family Doctor Name Family Doctor Phone

Consent Statement

I, the undersigned, authorize school staff to secure medical attention for my child if necessary and consent to emergency medical treatment as deemed necessary by a licensed medical professional.

Parent/Guardian Signature Date