RUSSIAN AMERICAN SCHOOL EMERGENCY AUTHORIZATION FORM
TODAY’S DATE__________________________
STUDENT INFORMATION
LAST NAME_______________________________FIRST______________________MIDDLE INITIAL____
DATE OF BIRTH_______________________________________________________________________
ALLERGIES/MEDICAL NOTES_____________________________________________________________
___________________________________________________________________________________
PARENT(S) /GUARDIAN(S) NAME(S)_______________________________________________________
CELL PHONE___________________________________HOME PHONE___________________________
EMERGENCY AUTHORIZATION
In an emergency, I hereby authorize the school to make such arrangements as necessary. I also authorize
the listed hospital to perform necessary procedures. I understand that the cost of medical attention and
ambulance are the responsibility of the parent.
NAME OF INSURANCE COMPANY__________________________________________________________
POLICY#_____________________________________________________________________________
I prefer my child be taken to________________________________________________________ hospital,
which is approved by the insurance company.
SIGNATURE OF PARENT/GUARDIAN:
____________________________________________________________ DATE ____________________
Please print this page, fill out & bring to your upcoming lesson. Thank you!