Student Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian 1 Phone *

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Student's Physician *

First Name

Last Name

Physician Phone Number *

(###)

###

####

I _____ give permission for my child to receive 200 mg of ibuprofen or 325 mg of acetaminophen while at WEB *

Do

Do Not

As the parent or legal guardian of the student list on this form, I do hereby consent to any medical care determined by a physician to be necessary for the welfare of my child while said child is under the care of Weekday Eastside Bridge (WEB) if I am not reasonably available by telephone to give consent. *

Consent

Do Not Consent

This form completed by: *

First Name

Last Name