*AA - Emergency Medical Care

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Use tab to navigate through the menu items.

Use tab to navigate through the menu items.

Child's Name:*

Date of Birth:*

Medical Care Information

Clinic Name:

Office Number:

Clinic Address:

Primary Care Physician:

Known Allegies:

Emergency Medical Care Authorization

By checking this box, I herby authorize Adventure Academy staff to give consent for all necessary emergency medical care for my child.

Signature

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Signature field is empty.

Date picker*

RURAL OFFICE OF COMMUNITY SERVICES

605-384-3883 | Fax 605-384-3737

107 S. Main Ave. Wagner, SD 57380

ROCS is a 501 (c)(3).

This organization is an equal opportunity provider.

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