EMERGENCY TREATMENT FORM 

302 Second St., SW

Roanoke, VA 24011-1502

540-345-1688

www.communityhigh.net

Name of Student:  ________________________________________________________

Address:________________________________________________________________

Parent:______________________________  Home Phone:  _______________________

Work Phone:______________________  Cell Phone:____________________________

Parent:______________________________  Home Phone:  _______________________

Work Phone:______________________  Cell Phone:____________________________

EMERGENCY TREATMENT AUTHORIZATION (Minimum of two contacts required)

Names of people to contact in case of accident or illness if neither parent can be reached:

Name:  ________________________________ Phone: ___________________________

Address:  _______________________________________________________________

Name:  ________________________________ Phone: ___________________________

Address:  _______________________________________________________________

Name of student’s physician: ________________________ Phone: _________________

Health insurance company: _________________________________________________

Policy no. ______________________________________________________________

1. In the event a parent or guardian cannot be reached, I/we give permission for Community High School to authorize emergency treatment for my/our child.

_______________________________________                  __________________

Signature of custodial parent                                       Date

3. The following are the only non-prescription dugs we have available.  Please mark those you authorize:

____Benedryl        ____Ibuprofen/Acetaminophen       ____antacid tablets

____throat/cough drops