SBH Authorization Form — Saint Benedict Hall

Aloha SBH Families!

We have a responsibility for the children that are at SBH, we want to make sure we have the necessary information and authorization in the event of a medical situation and for releasing your children to authorized drivers (other than parents).

The SBH Staff will call parents in the event of any medical emergency, but this form gives the SBH staff a heads up and directions of what to do with something that may happen to your child.

Below is a form that includes any medical information you’d like for us to know about (i.e. allergies, seizures etc.), and also information about medications that may be given. We can not and will not give any medication to your children unless expressly authorized in writing (this includes even things like children’s tylenol).

Please let me know if you have any questions.

In Gratitude,

Deacon Ben

Name of SBH Student:

Is there any medical information you'd like to share with SBH regarding your child?

If yes, please describe any medical information that you think will be helpful for the SBH staff to have regarding your child:

Would you like to authorize any medications to be given to your child while at SBH by a SBH staff member?

If yes, please list any medications and symptoms to watch for:

To Parents: Please provide your digital signature below to release the medical information to SBH provided above:

First Name

Last Name

Authorized Driver #1

Name of authorized driver #1 to pick up your child:

First Name

Last Name

Phone number of authorized driver #1 to pick up your child:

(###)

###

####

Authorized Driver #2

Name of authorized driver #2 to pick up your child:

First Name

Last Name

Phone number of authorized driver #2 to pick up your child:

(###)

###

####

Authorized Driver #3

Name of authorized driver #3 to pick up your child:

First Name

Last Name

Phone number of authorized #3 driver to pick up your child:

(###)

###

####

Authorized Driver #4

Name of authorized driver #4 to pick up your child:

First Name

Last Name

Phone number of authorized driver #4 to pick up your child:

(###)

###

####

2024 Medical and Pick-up Authorization Form