Emergency Medical Information Form printable pdf download

EMERGENCY MEDICAL INFORMATION FORM

Name__________________________________________________DOB:______________________________

Address_______________________________________________ Home Phone:________________________

Student Cell Phone:________________________

Health History:

Allergies (medication, insects, food, etc)

__________________________________________________________________________________________

Treatment for allergy:________________________________________________________________________

Dietary Restrictions:_________________________________________________________________________

Tetanus – last injection_____________

List and describe any current medical issues concerning your child that should be shared with the chaperoning

teacher(s) and emergency medical personnel.

__________________________________________________________________________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:

Name

Relationship

Home Phone

Work Phone

Cell Phone

1.________________________________________________________________________________________

2.________________________________________________________________________________________

3.________________________________________________________________________________________

This is permission for treatment of my child by physicians and at hospitals for any medical or surgical

emergency which may arise during the extended school-related field trip.

Health Insurance: (please attach a copy of insurance card or complete the following):

Insurance Company_______________________ID Number______________Group Number________________

___________________________________________________________________

Parent/Guardian Signature

Date

**Please sign and return this form to the teacher in charge of the trip/school sponsored event**

Rev 1/14

Emergency Medical Information Form