Citadel Christian School

Emergency Physician and Hospital Treatment Authorization

This form must be completed annually by parent or guardian. The School does not assume any financial responsibility but does want to provide the best emergency service. By signing this form, you are giving School Personnel the authority to call EMS or to obtain medical care if you or the emergency contacts cannot be reached.

Student’s Name – Last: Click here to enter text. First: Click here to enter text. Middle: Click here to enter text.
Student’s Date of Birth: Click here to enter text.
Father: Click here to enter text.	Home Phone Click here to enter text.
Address Click here to enter text.	Work Phone Click here to enter text.
Click here to enter text.	Cell Phone Click here to enter text.
Mother: Click here to enter text.	Home Phone Click here to enter text.
Address Click here to enter text.	Work Phone Click here to enter text.
Click here to enter text.	Cell Phone Click here to enter text.
Guardian: Click here to enter text.	Home Phone Click here to enter text.
Address Click here to enter text.	Work Phone Click here to enter text.
Click here to enter text.	Cell Phone Click here to enter text.
Emergency Contacts- Must include City, State, Zip	To be contacted after Father & Mother
Name Click here to enter text.	Home Phone Click here to enter text.
Address Click here to enter text.	Work Phone Click here to enter text.
Relationship Click here to enter text.	Cell Phone Click here to enter text.
Name Click here to enter text.	Home Phone Click here to enter text.
Address Click here to enter text.	Work Phone Click here to enter text.
Relationship Click here to enter text.	Cell Phone Click here to enter text.
Doctor Click here to enter text.	Phone Click here to enter text.
Dentist Click here to enter text.	Phone Click here to enter text.
Does student wear removable dental aids? Click here to enter text.	Does student have allergies? Click here to enter text.
Does student wear glasses or contacts? Click here to enter text.	If yes, name Drug Click here to enter text.
Has student had surgery or injury? Click here to enter text.	Food Click here to enter text.
If yes, what type? Click here to enter text.	Insect Click here to enter text.
Date of surgery or injury. Click here to enter text.	Other Click here to enter text.
Does student take medication on a regular basis? Click here to enter text.	Other Click here to enter text.
If yes, explain. Click here to enter text.
All prescription medicine should be accompanied by a note from the doctor giving the school instructions as to how to administer the medication.
Neither TAPPS nor the School assumes any responsibility in case of accident. If in the judgment of any representative of the School immediate treatment is needed, I request and authorize treatment to be given by any physician, trainer, nurse, or school representative. I do indemnify and hold harmless Citadel Christian School, any School representative or hospital representative from claim on account of such treatment of student.	Parent Signature: Click here to enter text. Date: Click here to enter text.