Emergency Information Form - Lancaster Mennonite Page 2
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1
2Special Health Concerns
Student Name: ______________________________ Grade: ________ Gender: _____
Asthma?
Yes
No
Emergency inhaler needed at school?
Yes
No
Seizures?
Yes
No
If yes, type? ___________________________________
Date of last seizure: ____________________________
Diabetes?
Yes
No
If yes,
Type 1
Type 2
Diet restrictions: _______________________________
Cardiac
Campus:
condition?
Yes
No
If yes, gym restrictions?
Yes
No
Kraybill
Lancaster
Severe
allergies?
Yes
No
peanuts
tree nuts
milk
shellfish
Locust Grove
other allergies: _______________________________
New Danville
Drug allergies?
Yes
No
If yes, please list: ______________________________
It is important to have
this information on file in
Other medical
conditions?
Yes
No
If yes, please list: ______________________________
the event of a medical
emergency or other
Emotional
emergency involving your
problems?
Yes
No
_____________________________________________
child. Although some of
Serious illness, injury hospitalization or operation?
Yes
No
this information is in our
If yes, date: ________________
Describe: ____________________________________
database or other school
Still under treatment?
Yes
No
records, a hard copy of
this sheet will be available
Restrictions on physical activity?
Yes
No
for easy access in
Describe: ________________________________________________________________
emergencies when the
computers may not be
Medications (taken at home or in school)
operational
.
Name: _________________ Dose: ____ Times: _________ Reason: ________________
Name: _________________ Dose: ____ Times: _________ Reason: ________________
Name: _________________ Dose: ____ Times: _________ Reason: ________________
Name: _________________ Dose: ____ Times: _________ Reason: ________________
Name: _________________ Dose: ____ Times: _________ Reason: ________________
glasses
contact lenses
hearing aids
ear tubes
other devices: __________________________________________________________
The school nurse may prepare a confidential list of students with significant health concerns
of which teachers and staff should be aware to protect the health and well-being of those
students. By signing below, you allow the nurse to share any health information she/he
deems appropriate for persons caring for your child to know.
The undersigned consents to the release of immunization records, physical and/or dental
exams from the student’s physician’s office.
Yes
No
Parent/Guardian signature: _________________________ Date: ____________________
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