I, , hereby authorize the White River School District to allow my child,, to receive emergency medical care at the Mellette County Health Clinic if I or a family member can not be reached in case of accident, injury, or severe illness at school.

For the doctor or physician assistant's information, my child is allergic to the following food or medications:

None

Parent (s) or Legal Guardians (s)

Date

For School Use Only:

Received by 

Date