**This form must be completed and submitted by March 23, 2020**
**Please complete one student Emergency Medical Information form per family**

Please print all information. In case of summer care-related accidents, illness or summer care dismissal communication, please complete.


If my child needs the following, I authorize summer care personnel to administer (check all that apply):

Administration of "over the counter" medication will be at the discretion of the appointed personnel, consistent with the recommended dose for age as defined on package guidelines.

Medical Release:

I hereby consent to any medical services that may be required while my child is under the supervision of an employee of the Bishop O'Gorman Catholic Schools summer care program and hereby appoint a Summer Care employee to act on my behalf in securing necessary medical services from any duly licensed physician or medical emergency provider. Responsibility for payment of ambulance, physician and/or hospital is that of the parent or guardian.

*You must notify the school if any of the above information changes.*