Office Copy

Dear Parent,

In order that we may know how to assist your child in case of illness or accident, please give the following information:

Child’s Name __________________________________________________

Telephone No. Home _________________________ Cell/Work_______________________

Place of work __________________________________________________________

Person to reach when not at home:. *Must have 2 accurate, reachable numbers*

1. _____________________________ 2. ______________________________

Family physician or clinic preferred:

1. _____________________________ 2. _______________________________

Hospital preference:

1. _____________________________ 2. _______________________________

Allergies or other health problems: __________________________________________________________________________________________________________________________________________________________________________

Any other special instructions: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Insurance Company _____________________________ TN. Care ____________________________

In case of a serious emergency when a parent cannot be reached, please sign below so that a school official may act in behalf of your child.

________________________________________ ________________________

Parent or Guardian Date

If none of the above people can be reached in an emergency situation, I hereby authorize the doctor on call at ________________________________________________ to treat my child.