Emergency Information
TEMPLE ACADEMY EMERGENCY & ILLNESS INFORMATION
(First Name Last Name)
/
/
(First Name Last Name)
(First Name Last Name)
Place of Work
Emergency Contact (list someone locally)
(First Name Last Name)
People who have permission to pick your child up from school:
(First Name Last Name)
(First Name Last Name)
(please indicate mild / severe allergy)
AUTHORIZATION FOR EMERGENCY CARE TO MINORS

If emergency treatment is required, and the parents or legal guardians cannot be reached immediately, your signatures below authorizes Temple Academy staff to exercise their own judgment to call the physician or dentist named above. If the physician or dentist named above is not available, your signatures below:
  • Authorizes Temple Academy staff to transport the child to a hospital emergency room
  • Authorizes any x-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist
  • Authorizes any physician or dentist to call in necessary consultants, at his/her own discretion
  • Authorizes the release of any medical records regarding the Emergency Room visit to Temple Academy for its files
Your signatures below encourage Temple Academy staff and any physician or dentist to exercise his/her/their best judgment in any diagnosis or medical, dental, or surgical treatment.
(First Name Last Name)
(First Name Last Name)
About Us
Temple Academy has been serving the Central Maine community with academic excellence for over 40 years!

Call to apply today!
207-873-5325
Address
60 West River Road
Waterville, ME 04901
Phone : 207 873-5325 | 207 660-4224
Email: school.office@templeacademy.org
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