I hereby authorize Grace School to allow my child to leave ONLY with the following persons. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.
In case of divorce/separation – if you wish non-primary/custodial parent to be a designated emergency contact/pickup, you must list below. Parents names must be listed.
List any special problems that your child may have such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medications prescribed for long-term continuous use, and any other information that could affect providing health services for your child:
Should a medical condition occur during a time in which I cannot be reached and immediate medical care is needed for the comfort or well-being of my child, I hereby appoint any employee or agent of Grace School as my attorney-in-fact to make such health care decisions for my child. For any act done in good faith under this power of attorney I hereby indemnify and hold harmless Grace School and the individual acting as my attorney-in-fact from any liability for the consequences of or the expenses associated with such act.
This power of attorney for health care decisions shall remain in effect until revoked in writing.