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18-19 Emergency Health Information

 PLEASE FILL OUT ONE FORM PER STUDENT

Grade*
State*

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People who have been authorized by parent/guardian to pick-up student if parent/guardian cannot be reached:

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I understand that the school does not assume responsibility for payment of a physician in any case. However, in an emergency, the school may choose a physician.*

Medical Insurance

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Is your student allergic to:

Any drugs?*
Any foods?*
Other (bee sting, etc)?*
Does your student have any chronic illness (asthma, diabetes, heart disease, epilepsy)?*
Does your student take any medications on a regular basis? *

, a minor, do hereby authorize a representative of Assumption Catholic School as agent(s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care that is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provision of the California Medicine Practice Act, on the medical staff of an accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

 It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required and is also given to provide authority and power on the part of the above-mentioned agent(s) to give specific consent to any such diagnosis, treatment or hospital care that the above mentioned physician, in the exercise of his or her best judgment, may deem advisable.

 This authorization shall remain effective until June 30, 2018, unless sooner revoked in writing and delivered to the above mentioned agent(s).