Medical Information 2 Medical Information Child Student's Last Name Student's First Name Known illnesses, medication or limitations: In case of emergency, contact: Nearest friend/relative: Phone: Physician's name: Physician's Phone: Insurance Information: Name of insured: Company: Policy Number: Group Number Please list any additional insurance info you would like us to have in case of emergency: TO ADD MORE STUDENTS: CLICK "Add another response" - FOUND JUST BELOW THE FIRST ENTRY Authorization I further authorize a representative of PAIDEIA CLASSICAL EDUCATION, a service of Parent And Child Educational Services (PACES) to take my child for any emergency medical treatment needed during school hours and I will be responsible for the charges incurred. Parent or legal guardian name: Additional/Secondary Parent or Guardian: Date: Date: By clicking below, I [we] fully authorize a representative of PAIDEIA Classical Education Service (PACES) to take my child for any emergency medical treatment needed during school hours and I [we] will be responsible for the charges incurred. I [we] agree and authorize PACES to take my [our] child[ren] for medical treatment in an emergency. Insurance Card scanned image: Please Note: In order to complete this form, we will need a copy of your current insurance card(s) to keep on record. Please scan the front and back and upload using the link above. If you don't have access to a scanner, please bring your card(s) to the school and we will make a copy for you. Need assistance with this form?