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Student Medical and Emergency Contact Form

Please complete a form for each child separately. If you have any questions or concerns, please reach out the the administration office by calling (773) 891-5130 or emailing [email protected].

Student Information

State*
Answer Required

Parent / Guardian 1 Information

Parent / Guardian 2 Information

Emergency Contact

Student Health Information

Condition*
Answer Required
Yes
No
Allergies (food, insects, drugs, latex)
Allergies (seasonal)
Asthma or breathing problems
Attention-Deficit/Hyperactivity Disorder
Behavioral problems
Developmental problems
Bladder problem
Bleeding problem
Bowel problem
Dental problems
Diabetes
Hearing problems or deafness
Heart problems
Seizures
Speech problems
Vision problems

Authorization To Consent To Medical Treatment

 

In the event my child becomes ill or injured at school or in a school-related event, and I cannot be reached, Cambridge Classical Academy is authorized to take one or more of the following actions: a.) Release my child to any of the people listed above; b.) Take my child to the physician indicated; c.) Take my child or have my child transported by ambulance to the hospital shown above and give consent for emergency care. Neither Cambridge Classical Academy nor its staff or agents are financially responsible for the emergency care and/or transportation related to my child’s condition.

Medical Consent Authorization*
Answer Required
Confirmation Email