2021-2021 EMERGENCY CONTACT INFORMATION
IS THE STUDENT TAKING ANY MEDICATIONS ON A REGULAR BASIS?
DOES YOUR CHILD REQUIRE AN EPI-PEN?
Which number is best to reach you?
Which number is best to reach you?

EMERGENCY MEDICAL INFORMATION

Please list two persons who may be contacted in case of emergency, illness, early dismissal, if parent or guardian cannot be reached.

Which number is best to reach them?
Which number is best to reach them?

In the event of an emergency, please list the following:

AUTHORIZED PICK-UP PERSON

Note: Special pick-ups not listed above must have written permission by parent/guardian.

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

In emergencies requiring immediate medical attention, your child will be taken to the nearest hospital emergency room. Your signature authorizes a responsible person at St. Martin's Lutheran School to have your child transported to a hospital.

I,                                                     ,hereby authorize emergency medical care for my child (name),                                            ,

if, in the judgment of the staff, treatment is required for any injury or illness. I hereby also authorize the administering of anesthetics and/or any other procedures deemed necessary by the attending physician. I understand that I will be notified at the earliest possible time should prior notice prove impossible. My child is allergic to the following medications and anesthetics:                                                                    

I understand that I am financially responsible for any expenses for medical care or transportation incurred on behalf of my child.

Signature of Parent or Guardian

Saint Martin's Lutheran School of Annapolis

Main Office: (410) 269-1955   |   Admissions: (410) 263-8016

1120 Spa Road Annapolis, MD 21403