HomeSchool PlayLab · Forms

Student Emergency Contact & Medical Form

Please complete all sections and return a signed copy to HomeSchool PlayLab staff.

Student Information

Student Name: ____________________________________________________

Date of Birth: ____________________   Grade/Level: _______________

Home Address: ____________________________________________________

City: ___________________________ State: ______ Zip: ___________

Parent/Guardian Contacts

Primary Contact

Name: ____________________________________________

Relationship to Student: ________________________________________

Cell Phone: _____________________   Email: _________________________

Secondary Contact

Name: ____________________________________________

Relationship to Student: ________________________________________

Cell Phone: _____________________   Email: _________________________

Emergency Contacts

If parents cannot be reached.

Name: __________________________ Relationship: ___________________

Phone: _________________________

Name: __________________________ Relationship: ___________________

Phone: _________________________

Medical Information

Primary Physician Name: __________________________________________

Phone: _________________________

Allergies (Food, Medication, Environmental): ____________________

__________________________________________________________________

Current Medications/Medical Conditions: __________________________

__________________________________________________________________

Authorized Pick-Up List

Please list all individuals authorized to pick up the student from the learning center (75-minute sessions).

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

Medical Authorization

In the event of a medical emergency, I authorize HomeSchool PlayLab (Academeer Inc.) staff to obtain necessary medical treatment for my child if I cannot be reached. I understand that I am responsible for all costs related to medical care and transportation.

Parent/Guardian Signature: _____________________________________

Date: _________________________________________________________