Permission for Medical Care

THIS FORM MUST BE COMPLETED AND RETURNED BEFORE JULY 15, 2018 OR STUDENTS WILL NOT BE ALLOWED TO ATTEND CLASSES

Parents: This form travels with your child when medical care is needed. Please address all areas on this form.

I hereby authorize the medical staff of the American Hebrew Academy Student Health Center or their designates, to carry out the necessary procedures for diagnosis, medical treatment, and minor surgical treatment for:

Student First Name *

Middle Name

Last Name *

Date of birth * +

Graduation Year *

Parent/Legal Guardian *

Relationship *

Date * +

Signature of Parent/Legal Guardian *

clear