Name (Last, First)____________________________________ Nickname _________________
Parents Name __________________________________________________________________
Address _________________________________________ City, State, Zip ________________
Home Phone ___________________________ Business Phone _________________________
Family Physician _______________________________ Phone _________________________
Grade ______ Age ______ T-shirt (Adult) S M L XL

The school has my permission, in an emergency when I (or my physician) cannot be contacted, to take my child to the emergency of the nearest hospital, and the hospital and it's medical staff have my authorization to provide treatment, which a physician deems necessary for the well-being of my child.