2025 Emergency Care Plan (ECP)

2025 Emergency Care Plan (ECP)
Student Information
Student’s Name*
Student’s Date of Birth*

MonthDayYear
Date
School*
Night of Event:*

MonthDayYear
Date
Emergency Contact 1 (Full Name & Phone #):
Emergency Contact1 *
Full Name
Emergency Contact 1*
Phone #
Emergency Contact 2*
Full Name
Emergency Contact 2*
Phone #
Authorization for Use or Disclosure of Protected Health Information Required by the Health Insurance Portability and Accountability Act, 45 C.F.R
I, First Name* Last Name* hereby authorize employees of the school listed on this form and their volunteers, Grad Nights Staff and their volunteers, and any relevant Healthcare Providers to disclose and release my child's protected health information provided in this form. This release is only valid in the event of medical need or emergency from date of signature. I agree to notify the Planning Committee of any changes to the information on this form between now and the date of graduation.
Signature of the Individual Giving this Authorization*
Date*

MonthDayYear
Date
Please list all life-threatening conditions:

AllergyAsthmaDiabetesCardiac IssuesSeizuresOther
If Allergy (Please specify)
Will the Senior be bringing any of the following onsite?

InhalerInsulin/Glucose MonitorEpi Pen (0.3mg)Epi Pen (0.15mg)Alergy MedicationOther
Allergy Medication
Please Specify
Who will carry the medication? Senior or Chaperone?
Please list side effects of any carried medication
Will the Senior be bringing separate food to the event?

YesNo
(Allergy) Senior should avoid contact with these allergens
(Asthma) Senior to avoid contact with these Asthma triggers
(Seizures) Senior to avoid contact with these seizure triggers
Immediate Response Plan

In the spaces below, please detail your Action Plan for each applicable life-threatening condition. Make sure to include who to contact and their contact details, if applicable.
Applicable life-threatening condition(s)
Action Plan and Contact Details
Please detail your action plan for each condition. Please include who to contact and their contact details, if applicable.
If needed, please use the back of this sheet for additional space. More details on the other side?

Yes
All information contained herein is strictly confidential, protected by copyright and intended for use only by current clients of Grad Nights. Use of this form, or any part or derivation by any committee, group or individual not currently working with Grad Nights is strictly prohibited. © 2000-2025 Grad Nights. Grad Nights® is a registered trademark of The Howard Group, Inc.
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2025 Emergency Care Plan (ECP)

Student Information

Emergency Contact 1 (Full Name & Phone #):

Authorization for Use or Disclosure of Protected Health Information Required by the Health Insurance Portability and Accountability Act, 45 C.F.R

Immediate Response Plan