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