Emergency Medical Form
Academic Year 2021-2022
Student Information
Insured Policy Holder's Information
Additional Parent/Guardian Contact Information
Additional Emergency Contacts (at least one required)
Health Insurance Coverage
Additional Information
Signatures
I hereby give permission to the administrators of Stone Hill Learning Center, or the teacher in charge, to arrange for my child to receive medical attention in the event of an emergency. I recognize that every effort will be made to contact me and/or the emergency contact person(s) named above.
