Form - Parent Consent and Emergency Information

Parent Consent and Emergency Information

Please fill out the form below.

My signature below indicates my permission for my scholar, who is named below, to participate in after school sports/activities at Heritage Academy. My signature also indicates that I have read and approve the medical treatment authorization.
EMERGENCY INFORMATION
Student Name*
First Last
Age*
Birthdate*
MM slash DD slash YYYY
Father's Name*
First Last
Mother's Name*
First Last
Day Phone for Father*
Day Phone for Mother*
Address*
Street Address City State ZIP Code
Family Doctor*
Doctor's Phone Number*
Allergies*
In an emergency, if the parents cannot be reached, please notify:
Name*
First Last
Phone Number*
Type of Phone*
MEDICAL TREATMENT AUTHORIZATION
In the event of illness or injury occurring to my child while participating in this activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental, or surgical), anesthesia or diagnostic procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical office staff furnishing such services.
I understand that, in the event of other than minor illness or injury, reasonable effort will be made to contact me.
I understand that there is inherent risk in many activities, and I hold Heritage Academy harmless and not liable for injury or accident, which may occur in the course of such activities. I willingly and ultimately assume the risk of such injury or accident.
Parent/Guardian Name*
Signature*
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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