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Child's Information
Mother's Information
Father's Information
Whom does the child reside with?
Person to notify in an emergency and parents cannot be reached:
Child's Physician
Child's allergies
Child's prescribed medications
Child's special needs or medical conditions
The medical facility the school uses is Cobb General Hospital.
In the event of an emergency and the parents cannot be reached, I hereby authorize any needed medical care and transportation of my child to a medical facility or evacuation location in the event the building must be evacuated. I further agree to be responsible for all medical expenses incurred during treatment of my child.
Parent / Guardian Signature
Witnessed by
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