Emergency Contact Form

In the event that a medical emergency arises and you can not be reached, do you authorize Charlotte Islamic Academy to undertake the steps necessary for the treatment of your child? *
I, undersigned, give permission to school official to act in my behalf in emergency situations to obtain medical treatment for my child. I agree to accept full responsibility for the payment of all ambulance, hospital, and physician’s bills or charges for any services rendered. *
Indicate the person other than parents to be contacted in case of an emergency:
Contact 1 - Name *
Contact 1 - Name
Contact 1 - Phone *
Contact 1 - Phone
Contact 2 - Name *
Contact 2 - Name
Contact 2 - Phone *
Contact 2 - Phone
Does the student have any persistent medical problems? *
Please check all that apply
Is the student taking medication regularly? *
Does the student have any allergies to specific foods or medications? *
Does the student have any mental disabilities? *
Does the student have any learning disabilities? Please check what’s applicable: *