Medical Emergency Information
Please fill out all information requested below
Student Name
*
First Name
Last Name
Student Gender
*
Please Select
Male
Female
Social Security Number
Birth Date
-
Month
-
Day
Year
Date
Current Age
Student Medical History
Physican Information
Name
Phone Number
Does your child have any special medical problem or allergies that the school should be aware of?
*
Yes
No
If yes, please explain.
The school is authorized to give my child Tylenol and/or Advil
*
Yes
No
The school is authorized to give my child Benadryl
*
Yes
No
The school is authorized to give my child antacid
*
Yes
No
Does your child take any other medications?
*
Yes
No
If yes, please specify with instructions.
Contact Information
Parent/Guardian Name
First Name
Last Name
Home/Cell Phone
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name 2
First Name
Last Name
Home/Cell Phone 2
Email Address 2
Address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If parents are seperated, with whom does the child live?
Alternate Emergency Information 1
*
Name
Phone
Relationship
Alternate Emergency Information 2
*
Name
Phone
Relationship
Alternate Emergency Information 3
Name
Phone
Relationship
List any other children enrolled in THIS school
In case of accident or serious illness, I request the school to contact me or the emergency numbers above. However, if the school is unable to reach anyone listed, I hereby authorize the school to call the physician indicated and to follow their instructions. If the physician cannot be reached, I request the school to make whatever arrangements necessary with the understanding that I am responsible for any and all medical bills not covered by insurance.
*
I agree to terms & conditions.
Parent/Guardian Signature
*
Submit
Should be Empty: