* In signing this document, I hereby certify that the above information is correct. In the event that I cannot be reached, I hereby give permission to the physician selected by the CMC staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for any of my children named below. (Check this box to grant permission.)

For those parents who will be submitting a printed version of this form, please sign and date it below.

Parent Signature _______________________________________ Date Signed ______________

1st Child's Name

2nd Grade
1st Grade
Kindergarten

2nd Child's Name

2nd Grade
1st Grade
Kindergarten

3rd Child's Name

2nd Grade
1st Grade
Kindergarten