Greenville Technical Charter High School

Medical Card

Please complete the form below. Mandatory fields marked *

Medical Information
  1. Father's Name:*
  2. Dad's Phone:
  3. Father's Employer:
  4. Father's Work #:
  5. In case of illness or injury when I cannot be contacted by the school authorities, I authorize the following relatives or friends to be contacted. In case of emergency, I agree to assume all expenses for moving and medically treating this student. I also hereby consent to any treatment, surgery, diagnostic procedures or the administration of anesthesia which may be carried out based on the medical judgment of the attending physician. The school will continue to call the parents, guardians or physician until one is reached.

  6. Doctor's #:
  7. Emergency Contact Name:*
  8. Emergency Contact Relationship:
  9. Emergency Contact Phone:













  10. If so, which?
  11. If so, which?
  12. Paperwork from health room needed for any medications/inhalers carried on student.

  13. ALL MEDICATIONS MUST BE DISPENSED THROUGH THE HEALTH ROOM unless proper paperwork is on file for inhalers, epi-pens, and rescue medications approved and endorsed by physician and parent.

Please enter the letters on the left to the area below.
Verification Code: (* required)
Can't see the characters?