Summer School Emergency Procedre/health Information Form - Howard County Public School System


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Summer School Emergency Procedure/Health Information
Please print all information clearly. Provide telephone numbers including area codes.
Current school: ____________________________________________ Summer School Site: ________________________________________
Student’s name: __________________________________________________________________________________ Date of birth: __/__/____
Last name
First name
Middle initial
Street address: ____________________________________________________________________________________________________
City: _____________________________________________________________________________ Zip code: ____________________
Home phone: (_______)_________________ Work phone: (_______)_________________ Cell phone: (_______)_________________
Parent/Guardian Name: _____________________________________________ Student/Family Primary Language: __________________
Family Physician: _____________________________________________________________ phone: (_______)_________________
Summer School Emergency Notification
(List in order of notification. Parent/Guardian will be contacted first unless otherwise specified.)
Major emergencies will be taken to the nearest hospital.
1. _________________________________________________________________________________________________________
Name of person
(area code) day time phone number
2. _________________________________________________________________________________________________________
Name of person
(area code) day time phone number
3. _________________________________________________________________________________________________________
Name of person
(area code) day time phone number
Other procedures desired: _____________________________________________________________________________________
Summer School Health Information
(For Health Room use)
List any health conditions/handicapping conditions: _______________________________________________________________
List any allergies: _____________________________________________________________________________________________
Describe the usual symptoms/reactions or any deviation from the usual reaction: ___________________________________________
Does your child have any activity restrictions?
No If yes, please explain. _________________________________________
Will any medication be needed at school?
No If yes, a written order from your Doctor is required. Medication forms are
available in any school health room.
• Immunization records, for children who have not attended school before, must be submitted and reviewed by the school nurse/
health assistant prior to the child attending summer school.
• The information you provide will be handled in a confidential manner. Information provided on this form will be reviewed and
discussed with staff as necessary to maintain your child’s safety.
• Information provided on this form must be in compliance with Health Services policy and procedure.
Parent/Guardian Signature _______________________________________________________________ Date ____/____/________
For office use only: please make a copy of this form, send original to Health Services Office at ARL.
Send copy to the Front Office of student’s summer school.


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