Emergency Contact & Medical Information

MA - Emergency Contact & Medical Information

Child's Name*
First Last
In case of emergency or if parents/guardian cannot be reached, the following people should be contacted:
Emergency Contact 1*
First Last
Relationship to child
Phone Number*
Cell Number*
Emergency Contact 2
First Last
Relationship to child
Phone Number
Cell Number
Emergency Contact 3
First Last
Relationship to child
Phone Number
Cell Number
Preferred Hospital*
In the event of a medical emergency, I/we prefer that our child be taken to:
*
If time is critical, the school has permission to take my child to the nearest hospital for emergency care. I agree to pay all expenses incurred by the handling of my child in this emergency.
- I agree
Insurance Provider:*
Name of Insured:*
Insurance Identification # :*
Insurance Group # :*
Pediatrician*
Please complete the following information regarding your child's healthcare providers.
First Last
Pediatrician Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pediatrician Phone Number*
Other Physician
First Last
Type of Physician
Other Physician Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Physician Phone Number
*
In the event of an injury to my child, or an existing condition indicating the need for minor first aid (e.g. band-aid, cold pack, splinter removal, etc.). I hereby give the Miriam Academy staff permission to administer these types of procedures.
- I agree
Parent / Guardian Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
Pin Number*
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Emergency Contact & Medical Information

MA - Emergency Contact & Medical Information

Miriam School

Grades K-8

Miriam Academy

Grades 9-12

Miriam Learning Center

Support Services

Miriam Switching Post

Resale Shop

Support Miriam

MA - Emergency Contact & Medical Information

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