GATES INTERMEDIATE SCHOOL
STUDENT HEALTH AND EMERGENCY INFORMATION SHEET
Please complete the following information below and return to school immediately.
Street Address: ___________________________________________________________________________________________________
Father’s Name: _______________________________________
Father’s cell: _________________________________________
Daytime phone: __________________________________
Daytime phone: _______________________________________
My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality):
My son/daughter is known to have the following allergies:
Please list any health concerns or issues:
Family physician: _______________________________________ Phone: _____________________________________________
Health Insurance provider: ________________________________ Policy Number: _______________________________________
*If you do not have health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health care
(restrictions may apply). Please contact the school nurse for more information about these programs. All communications will be confidential.
I give permission to have the school nurse or school personnel designated by the school nurse give the following medication in accordance with the
standing doctor’s order for the Scituate Public Schools prescribed by Dr. Stephen Lane, School Physician. (please check box):
Visine Eye Drops
Rhuligel or Calamine Lotion
Triple Antibiotic Ointment
I understand that every effort will be made to contact me, however, IN CASE OF EMERGENCY, I hereby give permission to the physician or hospital
to secure proper treatment for and order injection, anesthesia or surgery for my child.
Relationship to Student