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Emergency Contact and Medical Information for a Child

Emergency Contact

Child's Name*

Answer Required

Date of Birth*

Answer Required

Parent's/Guardian's Name 1*

Answer Required

Cell/Home Phone*

Number Required

Work Pone

Number Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Parent's/Guardian's Name 2

Answer Required

Cell/Home Phone

Number Required

Work Phone

Number Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Alternative Emergency Contact

Primary Emergency Contact

Answer Required

Relationship to Student

Answer Required

Cell/Home Phone

Number Required

Work Phone

Number Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Secondary Emergency Contact

Answer Required

Relationship to Student

Answer Required

Cell/Home Phone

Number Required

Work Phone

Number Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Medical Information

Hospital/Clinic Preference *

Answer Required

Physician's Name*

Answer Required

Physician's Phone Number*

Number Required

Insurance Company

Answer Required

Policy Number

Answer Required

Allergies/Special Considerations

Answer Required

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.*

Answer Required

Parent/Guardian Signature*

Answer Required

Date*

Answer Required

I give permission for my child to go on field trips. I release Los Angeles College Prep Academy and individuals from liability in case of accident during activities related to Los Angeles College Prep Academy, as long as normal safety procedures have been taken.*

Answer Required

Parent/Guardian Signature*

Answer Required

Date*

Answer Required