Name of Doctor: ____________________________________ Phone # _______________
Name of Dentist: ____________________________________ Phone # _______________
Health Plan/Insurance: ________________________________ Policy #_______________
Describe any medical conditions/problems:______________________________________________
_________________________________________________________________________________
My student is allergic to the following:_____________________________________________________
My student is taking the following medications:
Name of medication: ______________________________ Dose: ___________ Time:______________
Name of medication: ______________________________ Dose: ___________ Time:______________
The Discovery Charter School does not provide medical or accident insurance for students. Healthy Families is a low-cost, comprehensive health, dental and vision insurance for children ages one through eighteen, and for children on Medi-Cal with a share of cost. Application assistance for Healthy Families is available at the school. Requests further information when you submit this form.
Authorization to Treat a Minor: I hereby authorize and give my consent for emergency medical or dental care due to serious injury or illness if I or my designee cannot be reached. The physician named will be contacted or the student will be taken to an emergency room licensed under the Medicine Practice Act, at my expense. (Section 25.8 of the Civil Code of California.)
_________________________________________________ ________________________
Parent/Care Provider Signature Date