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Emergency Information Update
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Student Name  *
 
    
 Student Last Name                                          Student First                    

IN CASE OF EMERGENCY PLEASE CONTACT:
 
Parent 1    
Home Phone     Work Phone                      
Cell Phone     Other Phone    
       
Parent 2    
Home Phone     Work Phone    
Cell Phone     Other Phone    
       
Other than Parent    
Home Phone     Work Phone    
Cell Phone     Other Phone    
       
Doctor    
Phone    
       
       
CONTINUING CONSENT 
AND
AUTHORIZATION TO RELEASE INFORMATION
 
            We, the undersigned parent or guardian of  , a minor, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor under the general or special instruction of   , M.D., or any physician the school or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed above before any other physician is called by the school or other organization.
                It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize Yakima Adventist Christian School or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment.
                This consent shall remain in continuous effect until revoking in writing and delivered to Yakima Adventist Christian School
                We, the undersigned hereby authorize any hospital, physician, or other person who has attended or examined the minor to furnish to General Conference Insurance Service, or its representative any and all information with respect to any illness, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A copy of this authorization shall be considered as effective and valid as the original.
 
Signed by:

Father  Date
Mother Date
Guardian Date
Home    
Address    

 

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