Shadowing Emergency Medical Form

Junior High
Shadowing
Emergency Medical Form
_________________________________________________________________________________________________
Student’s Last Name (please print)
First
Middle
Birth date
Age
Grade
Home Phone
_________________________________________________________________________________________________
Address
City
State
Zip
_________________________________________________________________________________________________
Father/Guardian
Daytime Phone
Cell Phone
_________________________________________________________________________________________________
Mother/Guardian
Daytime Phone
Cell Phone
Is your child allergic to any medication? _____ If yes, please specify: _________________________________________
Is he/she allergic to bee stings? _____ If yes, what action should be taken? ____________________________________
Primary Care Physician _______________________________________________ Phone _________________________
Persons to whom my child may be released in the event of illness or emergency and I cannot be reached:
_________________________________________________________________________________________________
Name
Home Phone/Cell Phone/Work Phone
Relationship
Agreement and Release from Liability
Except for damages arising out of the willful negligence of Valley Christian Schools, I hereby agree to indemnify and hold
harmless Valley Christian Schools, its officers, directors, and employees, and any other organization co-sponsoring the
program, from and against any and all liability or injuries which I or my child may suffer arising out of or in any way connected
with my or my child’s participation in this program. In case of emergency, arising during or in connection with any activity,
I authorize any person in charge of the activity to consent to emergency expense, at my expense. I understand that Valley
Christian Schools is not obligated to carry any insurance to cover medical and / or dental treatment for me or my child. I
agree to pay any damages or expenses incurred by Valley Christian Schools due to my or my child’s negligence or disregard
of the rules of the program.
Insurance Co. which covers my child: ___________________________________________________________________
Policy # __________________________________________ Student ID # _____________________________________
Hospital Preference _________________________________________________________________________________
Date ___________________ Signature of Parent/Guardian _________________________________________________
VC036jh rev. 8/15
100 Skyway Drive #130 San Jose,CA 95111
(408) 513-2460 FAX (408) 513-2472
vcs.net