Student Contact And Emergency Form
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1
2STUDENT CONTACT AND EMERGENCY FORM
2016/2017
O
O
O
O
elementary
intermediate
junior high
high school
student’s name:
_____________________________________________________
DOB:
____________________
student’s address:
_____________________________________________________________________________
city:
_______________________________
state:
_____
zip code:
___________
phone:
___________________
parent’s/guardian’s name:
__________________________________________
cell:
______________________
work:
____________________________
e-mail:
______________________________________________________
parent’s/guardian’s name:
__________________________________________
cell:
______________________
work:
____________________________
e-mail:
______________________________________________________
WHEN PARENTS/GUARDIANS ARE UNAVAILABLE, LOCAL CONTACT:
name:
___________________________________________
relationship to student:
_______________________
cell:
______________________
work:
______________________
e-mail:
__________________________________
MEDICAL INFORMATION:
food allergies/intolerances that require food elimination, substitution or adjustment:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
list substitute or alternative foods:
_______________________________________________________________________
________________________________________________________________________________________________________
drug/environmental allergies:
___________________________________________________________________________
student health, safety or emergency care instructions (please note asthma, seizures, anaphylaxis or other
school related health conditions):
_______________________________________________________________________
please list medications administered at home:
___________________________________________________________
please list medications required during the school day:
___________________________________________________
PERMISSION FOR MEDICAL TREATMENT:
In the event that The Lab School is unable to reach any of the individuals named above promptly by phone, I/we authorize a Lab School
representative to secure any emergency medical or surgical care for my/our child. I/we agree to be personally responsible for the payment
of such medical expenses incurred. I/we authorize charges to be billed to my/our insurance company. I/we further authorize the facility at
which surgical or medical care is rendered to release all necessary information to my/our insurance company for reimbursement purposes.
insurance carrier:
__________________________________________________
subscriber #:
________________________
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Parent category: Medical