Christian Center Academy

Authorization for Emergency Medical Attention And Health Survey

Name of child: __________________________________ Birth date:_____________

Address: ______________________________________ Telephone:_____________

I hereby authorize a Christian Center Academy representative to call an emergency ambulance in case of a serious accident of acute illness. Your listed physician will be called if you are not available and may treat and do whatever is necessary to apply life-saving measures and first aid to your child.

It is understood that a conscientious effort must be made to notify me (parent/guardian) before such action will be taken. I also agree to accept responsibility for the cost incurred of above medical services.

The student is in        GOOD      FAIR       POOR     health at this time. Is there anything the school should know in regards to the student’s health?

_________________________________________________________________________________________________________

________________________________________________________________________________

Frequent colds Yes/No                        Bronchitis Yes/No                       Frequent infections Yes/No

Hearing deficiency Yes/No                 Convulsions Yes/No                     Frequent tummy aches Yes/No

Frequent ear infections Yes/No           Vision deficiency Yes/No

Frequent sore throats Yes/No              Must corrective lenses be worn? Yes/No

Diseases (please give dates)

Chicken pox ______            Asthma _____                     Scarlet Fever _____

Measles ______                  Whooping cough _____        Rheumatic Fever _____

Diphtheria ______              Polio _____                          Pneumonia _____

Diabetes ______                 Mononucleosis _____           Cancer _____

Tuberculosis ______           Hepatitis _____                   Epilepsy _____

Kidney Disease ______        Heart Disease _____          Mumps _____

Allergies __________________________________________________________________

Other ____________________________________________________________________

Operation: Appendectomy __________ Hernia _______ Tonsillectomy ________ Other ____________

Contact Information for emergency

___ Mother ___ Guardian __________________________________________________________

Phone: cell-______________________ home - ___________________ work ___________________

___Father ___ Guardian ___________________________________________________________

Phone: cell- _____________________ home - __________________ work _____________________

If parent(s) / guardian(s) cannot be reached, please notify

Name: ____________________________________ Phone (_____) _________________________

Doctor to call in Emergency

Name (MD)____________________ Address ___________________ Phone ___________________

Additional persons permitted to pick up in an emergency or from the learning center.

Name ________________________________________ Phone ______________________________

Name ________________________________________ Phone ______________________________

Name ________________________________________ Phone ______________________________

Name ________________________________________ Phone ______________________________

Name of Student _______________________________________ Age _________

Birth Date: _______________ Insurance Carrier:________________________________________

I (we), the undersigned parent(s) do hereby authorize the hospital most accessible during the time of accident or illness as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the medical staff of said hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

Mother’s signature:_______________________________________________ Date ______________

Father’s signature:_______________________________________________ Date ______________

Legal Guardian’s ________________________________________________ Date ______________

Guardian’s relationship: ___________________________________ Court paper: Yes/ No

This form must have two signatures / If your child is in the custody of one parent or guardian,

Please indicate. We also need custody court papers in their file (if necessary).