*Health - Emergency Information 2025-2026

Health / Emergency Information:

Child's Name (First and Last)

Mother (First and Last)

Mother Phone Number

Please enter a valid phone number.

Father (First and Last)

Father Phone Number

Please enter a valid phone number.

Guardian Name (First and Last)

Guardian Phone Number

Please enter a valid phone number.

Please provide the name, address, and phone number of at least two emergency contacts/authorized pickups in the case that a parent cannot be reached:

Name

Relationship

Phone

Address

Name

Relationship

Phone

Address

Name

Relationship

Phone

Address

People NOT AUTHORIZED to pick up my child

Relationship

Please provide the name, phone number, and address of the doctor and dentist you would like contacted in the event of an emergency.

Doctor

Phone

Address

Dentist

Phone

Address

Childcare Provider

Phone

In the event that your child becomes ill during the school day and needs medication for headaches, a temperature of 100.5 or less, or minor pain, please check one of the following: Yes, Tylenol (acetaminophen) or Ibuprofen may be administered to my child by school nurse. (Please note if you prefer one over the other No, Tylenol or Ibuprofen may not be administered to my child without consent from parent. Important health information (allergies, dietary restrictions, medical, other concerns):

Yes, Tylenol (acetaminophen) or Ibuprofen may be administered to my child by school nurse.(Please note if you prefer one over the other.)No, Tylenol or Ibuprofen may not be administered to my child without consent from parent.

Important health information allergies dietary restrictions medical other concerns

Health Information/Emergency

My child has asthma and needs to carry his/her inhaler with them at all times. The inhaler is properly labeled with instructions, and the above student has been properly instructed by their physician to self-administer their asthma medication.

YesNo

I give the school nurse/health aid permission to share the above information with only those school staff members who are involved with my child this school year.

YesNo

I authorize St. Mary's staff to act in an emergency situation when we (parents) cannot be reached in a timely manner.

YesNo

Parent Signature

Date

If your child will be using Transit Alternative (Otter Bus) after class, please sign and date the following authorization.

I, (Parent or Guardian Name) authorize Transit Alternative to transport my child from St. Mary's School.

Signature

Date

PRESCHOOL ONLY