St. George School Emergency Contact Information All Students in Family(Required)Student's Full NameStudent Grade Add RemovePlease list persons in order of preference for notification.Contact 1Parent 1 Full Name(Required)Phone HomePhone CellPlace of EmploymentWork PhoneEmail Contact 2Parent 2 Full NamePhone HomePhone CellPlace of EmploymentWork PhoneEmail Other Emergency ContactsOther persons who can be notified and/or who can pick up your child in the event of illness, accident or emergency if we are unable to contact you.Full Name and RelationshipPhoneFull Name and RelationshipPhoneFull Name and RelationshipPhoneIn case of emergency, I give my consent to proceed with needed treatment, surgery and anesthetic as deemed necessary by the attending physician. I hereby authorize the Osage Co. R-II School or St. George School to provide the physician, hospital or clinic with relevant data from the student file judged necessary for treatment. (Every attempt will be made to notify the family before treatment is given.)Emergency Consent to Treat(Required) Yes No You indicate your acceptance of the terms by typing your first and last name on the line below. This is the legal electronic equivalent of your signature.Parent/Guardian Name(Required)This is the equivalent of your electronic signature.Date(Required) MM slash DD slash YYYY Notification Email Please include an email if you would like to receive a copy of this form.
