Medical Form - Covenant Christian Academy

The following information will be used in the unlikely event of a medical emergency. CCA may seek medical treatment if a student is injured and his/her parent is not present or able to be contacted.

I hereby give permission to the staff of Covenant Christian Academy to obtain emergency medical health care for my child/children in my absence.

Parent's/Guardian's Electronic Signature *

Both Parents Names *

Street Address *

City State Zip Code *

Dad's Cell Phone *

Mom's Cell Phone *

Emergency Contact *

Emergency Contact Cell Phone *

Emergency Contact Relationship to You *

Doctor's Name *

Doctor's Phone Number *

Insurance Company Name *

Insurance Policy Number *

Student 1 Name *

Student 2 Name

Student 3 Name

Student 4 Name

Student 1 Date of Birth *

Student 2 Date of Birth

Student 3 Date of Birth

Student 4 Date of Birth

Student 1 Allergies (or NA) *

Student 2 Allergies (or NA)

Student 3 Allergies (or NA)

Student 4 Allergies (or NA)

Student 1 Meds (or NA) *

Student 2 Meds (or NA)

Student 3 Meds (or NA)

Student 4 Meds (or NA)

Stdt 1 Health Needs (or NA) *

Stdt 2 Health Needs (or NA)

Stdt 3 Health Needs (or NA)

Stdt 4 Health Needs (or NA)