St. Walburga Monastery Grounds

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Emergency and Medical Information Contact Form

Please complete the form below. Required fields are marked with an asterisk *

State*
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Student Resides With:*
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Parent/Guardian Contact Information

State*
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Secondary Contact State*
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Medical and Insurance Information

Special Health Considerations

  • In case of accident or serious illness, I request that the school contact me.
  • If the school is unable to reach me, I hereby authorize the school to call the physician indicated above and to follow the physician's instructions.
  • If it is impossible to contact the physician, the school may take whatever arrangements deemed necessary.
  • If I cannot be reached at the above address and phone number, you have my permission to contact either if the following:

STUDENTS WILL ONLY BE RELEASED TO PERSONS LISTED ON THIS EMERGENCY FORM. 
THIS PERSON MUST BE 21 YEARS OF AGE OR OLDER AND MUST PRESENT PHOTO IDENTIFICATION.

By providing your digital signature below, you are confirming that the information you have provided above is true and accurate. Additionally, you are providing permission for your child to be picked up by the person or persons you've identified as your emergency contacts.*
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Confirmation Email