*AA - Emergency Medical Care

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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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Date picker*

Contact Us

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

ROCS Business Office:

107 S. Main Ave. Wagner, SD 57380

Yankton Outreach Office:

920 Broadway Ave. | 605-665-4559

Mitchell Outreach Office:

201 E. 2nd Ave. | 605-996-9626

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