Emergency Medical Form - School year 2017/2018

Child's Name: *
Child's Name:
Primary contact parent: *
Primary contact parent:
Emergency contact person (if primary contact parent cannot be reached): *
Emergency contact person (if primary contact parent cannot be reached):
2nd Emergency Contact Person
2nd Emergency Contact Person
Clinic Address:
Clinic Address:
Especially food, insects or medication. Please note that if any treatment or medication is necessary, a doctor’s confirmation and/or instruction is required.
Please describe any medical condition or pertinent information about your child’s physical and/or emotional health, which should be known to the school for your child’s protection.
By signing this form, I certify that my child’s immunizations against Diphtheria, Tetanus, Measles, Polio and Whooping Cough are up to date.

While the LTC School’s teachers and/or parents will do everything possible to ensure a safe environment for your child, please be aware that the WAC cannot be held responsible for accidents which occur on our premises. Receipt and signature of Emergency Medical Form will indicate agreement with, and acceptance of, the above statement.
Online Signature*