Each student at SF Day needs an individual Emergency Contact and Release Form. Please fill out this form for each child enrolled at SF Day. The form needs to be electronically signed by ALL parents/legal guardians. If you experience difficulties online, please email mphillips@sfday.org.

Student First Namerequired

Student Last Namerequired

Student Date of Birthrequired (mm/dd/yyyy)

Student Weight in lbs. (approximate)required

Student's Grade Level for 2020-21required

Emergency Contact 1 - Full Namerequired

Emergency Contact 1 - Phone Numberrequired

Emergency Contact 1 - Email

Emergency Contact 2 - Full Name

Emergency Contact 2 - Phone Number

Emergency Contact 2 - Email

Out of State Contact - Full Name

Out of State Contact - Phone Number

Out of State Contact - Email

Medical Information & Accident Release*

In case of accident or serious illness, I request SF Day to contact me. If the School is unable to reach me, I hereby authorize the School to call the physician indicated below and to follow his/her instructions. If it is impossible to contact this physician, the School may make whatever arrangements seem necessary. In the event of an emergency or non-emergency situation requiring medical or dental treatment, I hereby grant permission for any and all medical and dental care to be administered to me or the Student. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery under the supervision of and upon the advice of qualified medical or dental personnel. I authorize School staff members to transport me or the Student in a personal vehicle in case of a medical emergency. I further authorize the School to release the Student’s personal information necessary for medical, dental, or insurance purposes. I hereby release the Released Parties from any and all liability for medical or dental aid rendered, and I understand that I am responsible for all medical or dental expenses incurred for such aid.

Yes No

Physician Full Namerequired

Physician Phone Number

Family Medical Group

Hospital

Dentist Full Name

Dentist Phone Number

Orthodontist Full Name

Orthodontist Phone Number

Medical Emergency Authorization*

I/we, as parents/legal guardians of the minor named above, do hereby authorize San Francisco Day School and its adult employees and representatives as the agent for the undersigned to consent to emergency medical or dental care for the above named minor, including x-ray, MRI, and other diagnostic imaging examination, and anesthetic, dental, medical, or surgical diagnosis or treatment, hospital care under the general or special supervision and upon the advice of or to be rendered by physician and surgeon licensed under the Medical Practice Act or a dentist licensed under the Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to our agent to give specific consent to any and all such diagnosis, treatment or hospital care which the physician, surgeon or dentist in the exercise of his/her best judgment may deem advisable. This authorization is given pursuant to the provisions of sections 6901-6910 of the California Family Code. If this authorization is executed by only one parent or custodian, I hereby certify that I have sole legal custody of the above-named minor. I/we also agree to assume any and all financial responsibility for emergency care and services to the above-named minor, including transportation services. This authorization shall remain in effect so long as the above-named minor remains a student of the School, unless and until a written revocation is delivered to the Head of School.

Yes No

Children's Aspirin Substitute Authorization*

I hereby authorize SF Day to dispense children's aspirin substitute to my child when deemed advisable.

Yes No

Allergy Information

Please list any food, drug, or other allergies. If the allergy is life-threatening, please send a detailed list of emergency protocols for the student to the front office staff.

Medication Information or Other Medical Concerns

Please share any information regarding medications or medical concerns you have for the student.

My child uses an Inhaler.*

Yes No

My child uses an Epipen.*

Yes No

Parent/Guardian 1 Signature (type your full name)required

Parent/Guardian to be the School's primary contact for all invoices and correspondence.

Daterequired (mm/dd/yyyy)

Parent/Guardian 2 Signature (type your full name)

This is required if the child has more than one parent or guardian.

Date (mm/dd/yyyy)

I hereby certify that I have sole custody of the above-named student.

Please select "yes" if the foregoing is executed by only one parent or guardian.

Yes No