Medical Treatment Parent/Guardian Consent Form

Student Information

Full Name

Date of Birth

Grade

Address

Parent/Guardian Information

Parent/Guardian Name Relationship to Student

Phone Number

Alternate Phone Number

Medical Information

Doctor's Name Doctor's Phone Allergies Current Medications Medical Conditions

Consent

I, the undersigned, hereby give permission and consent for the student named above to receive medical treatment by qualified medical personnel in case of illness or emergency during school activities or off-site events.

Parent/Guardian Name (Printed)

Signature

Date