Medical Info

Medical Information and Consent Form

St. John the Baptist Catholic School, Red Bud
Student Name

First NameLast Name
Birth Date

MonthDayYear
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name
Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Physician's Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does the student take medications regularly?
If yes, please describe
Does the student have any chronic illnesses?
If yes, please describe
Is the student allergic to any drugs or medications?
If yes, please desribe
Does the student have any known food allergies?
If yes, please describe
In the event that my child name, requires emergency medical treatment due to illness or injury, I hereby give my consent to the following:
1. personnel supervising my child to arrange for emergency medical care at an appropriate medical facility;
2. medical personnel at the medical facility to render necessary treatment to my child.
I further acknowledge and agree that I will assume responsibility for payment of all expenses associated with the medical care above described.
Signature
Date

MonthDayYear
Should be Empty:

Medical Information and Consent Form