Student's Name: Last, First

Student's Name: Last, First

Student's Name: Last, First

Student's Name: Last, First

Student's Name: Last, First

Student's Name: Last, First

Student's Name: Last, First

I am the parent/legal guardian of above-named student(s) and hereby authorize any necessary emergency medical treatment for the above-listed child(ren) while participating in Hemet Christian Homeschool Families co-op (HCHF co-op) 

I understand that HCHF will make every reasonable attempt to contact me in a timely manner in the event of an injury to my child(ren) that requires emergency treatment, and this form is to be relied upon only in the case of an extreme emergency when I, the parent/legal guardian, must leave the premises of HCHF co-op, or am otherwise unavailable.

I hereby authorize to hold harmless HCHF, its directors, organizers, teachers, volunteers, or agents for the consequences of exercising their best judgment regarding the need for emergency treatment of my child(ren), as contemplated by this authorization.

Medical Insurance Company -  (Health Information is mandatory, If you do not have health insurance please put none)

Policy #:

Group #:

Student’s Address:

Current Medications/Dosage:

Allergies:

Emergency Contacts (name/relationship/phone#):

Parent's electronic signature: (full name)

Date: