North Orange County Community College District School of Continuing Education
Child's Name:             DOB _____/_____/_____
Last First   Male   Female
Address:             Student ID #  @  
Street City Zip
Parents or Guardian with Telephone (       )    
Whom Student Lives   Relationship to Student  
Work phone: (           )     Cell phone or Pager: (          )__________________________________
Alternate contact's name:         Telephone (       )    
In the event emergency personnel must be called are there any medical/health conditions they should be aware of   Yes____ No____
If yes, describe the condition:________________________________________________
Family physician name ________________________________  Telephone Number (          )___________________
Does your child take any medication regularly?   Circle one       YES      NO
If yes, what is the name of the medication and dosage?   ______________________________________
In the event of illness or injury and school personnel are unable to contact parent/guardian and or family physician, I hereby
consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment or hospital care and
and transportation considered necessary in the best judgment of the attending physician, surgeon or dentist.  I further
acknowledge that the District/School does not provide medical coverage for my child.   ________________________________
          Initials Date
My child is NOT to be released in the event of an emergency or disaster to:_______________________________
Check below which sites attending
_______________________________ _____________________   Cypress   Anaheim  
Signature Date □ Wilshire   Yorba Linda