Emergency Medical Form

Emergency Medical Form

Please fill in the form below.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *

Area Code Phone Number
Father's Work Phone *

Area Code Phone Number
Mother's Work Phone *

Area Code Phone Number
Insurance Co: *
Insurance Card #: *
Insurance Policy #: *
Doctor's Name:
Doctor's Address:
Office Phone

Area Code Phone Number
Emergency Phone

Area Code Phone Number
E-mail *
Medical History
Has your student ever had any of the following:
Appendicitis

Yes No
Asthma or Hay Fever

Yes No
Hernia (Rupture)

Yes No
Rheumatic Fever

Yes No
Diabetes

Yes No
Does Student take insulin

Yes No
Poliomyelitis

Yes No
Heart Trouble

Yes No
Scarlet Fever

Yes No
Sever Allergies

Yes No
Significant Disease, Injury or Operation

Yes No
Medical History that requires medication

Yes No
Any activities restricted due to medical

Yes No
Is your student subject to any of the following:
Sinus Trouble

Yes No
Fainting Spells

Yes No
Ear Trouble

Yes No
Convulsions

Yes No
Poison Ivy, Oak or Sumac

Yes No
Reaction to Penicillin

Yes No
Nervousness/Easily Upset

Yes No
Allergies

Yes No
Date of last Tetanus Shot
If you answered "Yes" to any questions, please explain:
Should be Empty: