Health And Emergency Information Form
ADVERTISEMENT
1
2Health and Emergency Information Form
THIS FORM MUST BE TURNED INTO THE OFFICE ON THE FIRST DAY OF ATTENDANCE
Student’s Name: ____________________________________________________
Please list any pertinent medical problems, such as allergies, reactions to drugs, or
any other conditions to safely treat your child in an emergency. Please note: This
information will be shared with staff.
________________________________________________________________________
________________________________________________________________________
Please list any dietary restrictions or habits: _________________________________
Parent/Guardian Name: ____________________________________________________
Address: __________________________________________________________________
Employer: _________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Parent/Guardian Name: ____________________________________________________
Address: __________________________________________________________________
Employer: _________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Physician’s Name: _________________________Phone Number: _____________________
Insurance Company: __________________________________________________________
Group Number: ____________________ Policy Number: _____________________________
Dentist’s Name: ___________________________ Phone Number: _____________________
In a medical emergency, the following people may authorize medical care for the child
named above:
Name: ___________________________________________________________________
Address: __________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Please fill out both sides of this document.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business