RUSSIAN AMERICAN SCHOOL EMERGENCY AUTHORIZATION FORM

 

TODAY’S DATE__________________________

 

STUDENT INFORMATION

LAST NAME_______________________________FIRST______________________MIDDLE INITIAL____

 

DATE OF BIRTH_______________________________________________________________________

 

ALLERGIES/MEDICAL NOTES_____________________________________________________________

 

___________________________________________________________________________________

 

PARENT(S) /GUARDIAN(S) NAME(S)_______________________________________________________

 

CELL PHONE___________________________________HOME PHONE___________________________

 

EMERGENCY AUTHORIZATION

In an emergency, I hereby authorize the school to make such arrangements as necessary. I also authorize

the listed hospital to perform necessary procedures. I understand that the cost of medical attention and

ambulance are the responsibility of the parent.

 

NAME OF INSURANCE COMPANY__________________________________________________________

 

POLICY#_____________________________________________________________________________

 

I prefer my child be taken to________________________________________________________ hospital,

which is approved by the insurance company.

 

SIGNATURE OF PARENT/GUARDIAN:

 

____________________________________________________________ DATE ____________________