2020-2021 PARENT CONSENT FORM

Please complete the form below. Required fields marked *

PARENTAL CONSENT FORM

2020-2021

Student's Last Name:*

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Student's Legal First Name:*

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Student's Preferred Name: ( Please put N/A if it does not apply)*

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Date of Birth:*

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Grade as of September 2020*

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Dear Parent:

Please read the following carefully and sign below:

In case of a medical emergency, accident or serious illness, while my son is on the school premises or under the school’s supervision, I request that the school contact me. If the school is unable to reach me, I, hereby, authorize the school to call my son’s physician listed below and to follow his/her instructions. If the school’s efforts to contact me or my son’s physician are unsuccessful and/or if the situation is considered dire, the school may have my son taken to the emergency room of Holy Name Hospital, Hackensack University Medical Center, or the nearest available hospital for medical treatment.

Physician’s Name: *

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Physician's Telephone Number:*

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Name of Insurance Carrier:*

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Insurance Policy Number: *

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Please provide a photocopy of your son's insurance card.

I give permission for my child to participate in the following nursing services provided by TABC. These services include:*

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Administer Tylenol or Advil upon request

Providing nursing services for school related injuries

Maintaining health records

Administer appropriate treatment by the nurse for illness while in school

In the freshman and junior year, there are State mandated health screenings. IF YOU WOULD LIKE YOUR SON TO BE EXEMPT FROM ANY SCREENING, PLEASE INDICATE BELOW:

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Exempt all screenings

Hearing

Vision

Height

Weight

Blood Pressure

Scoliosis

N/A

Persons to contact in case of emergency: Please include three names and telephone numbers:

Contact 1:

Name:*

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Street Address*

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City*

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Zip/Postal*

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Best Contact Phone #*

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Additional Phone #

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Contact 2:

Name:*

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Street Address*

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City*

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Zip/Postal*

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Best Contact Phone #*

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Additional Phone #

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Contact 3:

Name:

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Street Address

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City

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Zip/Postal

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Best Contact Phone #

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Additional Phone #

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Sharing Medical Information: ( SIGNATURE REQUIRED)

I give consent for my child's medical information to be shared, when necessary, with the school personnel to insure proper care, and treatment while my child is participating in school activities.*

Parent Signature:

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I hereby give permission to my son to leave the school grounds during those periods of the school day permitted by the administration.

Parent's Signature:*

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Date:*

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Please fix the highlighted areas below before submitting.

2020-2021 PARENT CONSENT FORM