TopBridge Academy

Emergency Medical Authorization

Authorization for Emergency Medical Treatment

Required before enrollment. Grants consent for emergency care if parents cannot be reached.

Fill all required fields, check the authorization box, sign, then tap Sign, Download & Submit.

Student Information

Student Name *

Date of Birth *

Grade

Parent / Guardian

Name *

Phone *

Relationship

Emergency Contacts

At least one emergency contact is required if parents cannot be reached.

Contact 1 *

Contact 2 (Optional)

Physician & Insurance

Physician Name *

Physician Phone

Insurance Provider

Policy Number

Preferred Hospital / Emergency Facility

Medical Details

Medical Conditions

0/500

Allergies

0/500

Current Medications

0/500

Authorization

I authorize emergency treatment *

I authorize TopBridge Academy staff and emergency personnel to seek and administer any necessary emergency medical treatment for the above-named student if I cannot be reached. I understand I am responsible for all medical expenses incurred.

Parent / Guardian Signature

Digital Signature *

Sign here with your finger or mouse

Printed Name *

Date *

Your PDF will download automatically. A copy is also sent to the school office.