FAITH AND FOUNDATIONS EDUCATION LLC
Student Medical Information, Allergies & Emergency Care Form
Please complete this form so Faith and Foundations Education LLC can be aware of important health, allergy, medication, and emergency information that may affect your child's safety or participation.
1. Student & Parent/Guardian Information
Student Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Primary Care Information
Primary Care Provider:
Provider Phone:
Format: (000) 000-0000.
Preferred Hospital/Medical Facility:
3. Medical History
Does your child have any current or past medical conditions, significant illnesses, surgeries, injuries, or other health history we should be aware of?
No
Yes
If yes, please explain, including any information that may affect participation or require special attention:
Does your child have any physical limitations or activities they should avoid?
4. Allergies & Reactions
Does your child have any allergies?
No known allergies
Yes
Select all that apply:
Food
Medication
Environmental
Insect/Sting
Latex
Other
Please list each allergy and describe the reaction/severity:
Does your child carry an EpiPen or other emergency allergy medication?
No
Yes
Medication:
5. Medications
Does your child currently take any prescription or over-the-counter medications that we should know about?
No
Yes
Medication(s), dosage, timing, and relevant instructions:
Will your child have any medication with them during a program?
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No
Yes
If yes, please provide instructions:
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6. Dietary & Other Health Information
Does your child have dietary restrictions or food-related needs?
None
Allergy
Intolerance
Medical/Religious/Other Restriction
Please explain:
Are there any other health, sensory, behavioral, or safety considerations that an instructor should be aware of to appropriately support your child?
7. Health Insurance Information
Insurance Provider:
Policy/Member Name:
Policy/Member ID:
Group Number (if applicable):
Insurance Phone:
Format: (000) 000-0000.
Please provide a copy/photo of the insurance card if required by your program policies.
8. Emergency Contacts
Primary Emergency Contact
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Secondary Emergency Contact
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
9. Emergency Instructions
In the event of an emergency involving my child, I would like Faith and Foundations Education LLC to:
Emergency Instructions
Call 911 immediately when emergency medical assistance appears reasonably necessary, then contact me.
Contact me first when reasonably possible, while calling 911 if emergency assistance appears necessary.
If I cannot be reached, contact my emergency contact and obtain emergency medical assistance if necessary.
Other instructions:
Hospital/Facility Preference (if reasonably possible):
Additional Emergency Instructions:
10. Emergency Medical Care Authorization
I understand that Faith and Foundations Education LLC is an educational business and is not a medical care provider. In an emergency, staff may contact emergency services and seek appropriate emergency medical assistance for my child when reasonably necessary. I understand that Faith and Foundations Education LLC cannot guarantee a specific medical outcome or facility and that I am responsible for applicable medical expenses. I authorize Faith and Foundations Education LLC staff or designated representatives to provide reasonable assistance, contact emergency services, and communicate relevant information from this form to emergency responders when necessary for my child's safety.
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11. Parent/Guardian Acknowledgment & Signature
■I certify that the information provided on this form is accurate and complete to the best of my knowledge. I agree to notify Faith and Foundations Education LLC promptly if my child's medical, allergy, medication, insurance, or emergency information changes.
Parent/Guardian Signature:
Printed Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Name:
First Name
Last Name
For Faith & Foundations Education LLC Use
Date Received/Reviewed:
Staff Notes:
Follow-Up Needed:
Faith and Foundations Education LLC
Growing minds. Building character. Strengthening foundations.
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