Father: Name_________________________________________ Cell Phone ___________________________
Employer___________________________________ Work Phone_________________________
Employer Address_______________________________________________________________
Street City State Zip Code
Employer___________________________________ Work Phone_________________________
Employer Address_______________________________________________________________
Street City State Zip Code
Incarnate Word Academy
Student Emergency Form (2021-2022)
Student Name: ___________________________________________________________________________
Last First Middle
Birth Date: ____________________________________
Year: Fr____ / So____ / Jr____ / Sr____
Address: _________________________________________ City/State/Zip:___________________________
Student Cell Phone:__________________________________ Home Phone:____________________________
Emergency Contact Information
Mother: Name _______________________________________ Cell Phone ___________________________
Insurance Plan: ___ HMO ___ PPO ___ N/A
Health Information
List any health conditions such as heart disease, diabetes, epilepsy, severe allergies, allergies to medications, eye
or ear problems, or any chronic conditions:
List medications being taken: _________________________________________________________________
Food Allergies
Doctor Name: _____________________________________ Office Phone #: __________________________
Preferred Hospital: _________________________________________________________________________
Hospital Name Address Phone#
I, the undersigned, do hereby authorize school administration to render first aid for illness or injury to my daughter named above. In the event of a medical
emergency, I authorize school administration to have my daughter transported to the nearest hospital/emergency care center for emergency medical or surgical
treatment and to contact my daughter's physician and one of the persons listed above. I further authorize the release of the above medical information to all medical
personnel providing treatment. I agree to be solely responsible for the payment of all expenses incurred in such an emergency. I do hereby release, hold harmless and
indemnify Incarnate Word Academy and any other of their officers, agents, employees or representatives ("Released Parties") from any and all liability, claims,
losses or expenses arising from personal injury, death, or loss of or damage to property arising from any medical treatment received and/or transportation to the
nearest hospital/emergency care center. This form may be signed in counterparts and may be delivered by facsimile or other electronic means, each of which may be
deemed an original, and all of which together constitute one and the same agreement.
Parent Signature (First, Middle, and Last Name): _____________________________ Date: ___________
My daughter is covered by the above policy: ___ Yes ___ No.
Private (Primary) Insurance Information
Ins. Co. Name ______________________________________ Pre-authorization Phone # _______________
Insurance Company Address ________________________________________________________________
City/State/Zip: ____________________________________________________________________________
Name of Insurance Policy Holder ______________________ Date of Birth __________________________
Policy Holder’s Employer ___________________________________________________________________
Employer’s Complete Address ________________________________________________________________
Policy Holder’s SS# _____________ Group # ___________ Policy # ___________ ID/other # __________
List person(s) to be contacted in case of emergency when parent/guardian cannot be reached.
Name
Phone Number Relationship
