St. Mary's Parish School - Emergency Form 2023-2024

St. Mary's Parish School - Emergency Form 2023-2024
Child's name*

First NameLast Name
Date of birth

MonthDayYear
Date
Email
example@example.com
Mother’s/Guardian’s name

First NameLast Name
Business Phone no.
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Father’s/Guardian’s name

First NameLast Name
Business Phone no.
Please enter a valid phone number.
Cell
Please enter a valid phone number.
LIST ALL ALLERGIES AND/OR SPECIAL NEEDS:
MEDICATIONS: Per the Parent Handbook, the school is not able to give any medicine without the express written permission and details of the parent or guardian. For prescriptions, parents need to abide by the “Medications” section of the Parent Handbook. All medicines are to be kept with the Secretary in the school office. In compliance with Diocesan Policy, non-prescription medications (aspirin, cough medicine, etc.) MUST have a written request by the student(s) parent(s). Inhaler and epi pens are only to be used by a student with staff supervision.

In the event of serious illness or accident when we, the parents, cannot be reached, we wish one of the following local people to be notified by telephone. They are authorized to act in my/our absence and will be informed that their names have been used.
Emergency contact Name - 1

First NameLast Name
Emergency contact - 1 Phone Number
Please enter a valid phone number.
Emergency contact Name - 2

First NameLast Name
Emergency contact - 2 Phone Number
Please enter a valid phone number.
If needed, we authorize the school to contact our family doctor or dentist.
Family Doctor Name
Phone Number
Please enter a valid phone number.
Family Dentist
Phone Number
Please enter a valid phone number.
As the parent or legal guardian of the child(ren) listed on the registration form, we hereby give consent for emergency medical care. This care may be given under whatever conditions are necessary to preserve the life, limb, or wellbeing of my child(ren). Recognizing the possibility of physical injury, we hereby release, discharge and/or indemnify St. Rose/St. Mary School, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields, and facilities utilized for the programs against any claim by or on behalf of the registrant(s) as a result of the registrant’s participation or being transported to or from the same, which transportation we hereby authorize. We, the parents/guardians of the registrant(s), a minor, agree that we will abide by the rules of St. Mary’s School and its affiliated organizations and sponsors.

Agreed
Signature Parent/Guardian

Clear
Date

MonthDayYear
Date
Signature Parent/Guardian

Clear
Date

MonthDayYear
Date
IGNITING faith, knowledge, creativity and service
Should be Empty:

St. Mary's Parish School - Emergency Form 2023-2024

If needed, we authorize the school to contact our family doctor or dentist.

IGNITING faith, knowledge, creativity and service