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Temple Academy Athletic Department Emergency Information Card

Student name: *

(First Name Last Name)

DOB: *

/

/

Primary physical address: *

Emergency contact info:

Mother name: *

(First Name Last Name)

Home phone #: *

Cell phone #: *

Work phone #: *

Father name: *

(First Name Last Name)

Home phone #: *

Cell phone #: *

Work phone #: *

Guardian name: *

(First Name Last Name)

Home phone #: *

Cell phone #: *

Work phone #: *

Student Allergies: *

Current Medications: *

Additional information that may be helpful:

Family doctor: *

Phone #: *

In case of an accident or serious illness I request notification but grant authorization for an appropriate authority to consent emergency medical treatment for my child/person for whom I am parent/guardian

Parent/Guardian's Electronic Signature: *

(First Name Last Name)

Insurance/group number:

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 | 207-203-4197
Email: school.office@templeacademy.org

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