Confidential Student Health Emergency Information Form/melrose Public Schools
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1MELROSE PUBLIC SCHOOLS - CONFIDENTIAL STUDENT HEALTH AND EMERGENCY INFORMATION
Student’s Name: _________________________________________________________ Grade:___________________
Last/First/Middle
Address:__________________________________________________________________________________________
Date of Birth: ________________________ Sex: Male/Female Primary Language: ________________________
Resides With: __________________________________________ Home Telephone: _________________________
Parent/Guardian #1 Name: ________________________________ Home Telephone: ________________________
Parent/Guardian #1 Work Telephone: _________________________Cell Telephone: ________________________
Parent/Guardian #2 Name: ________________________________ Home Telephone: ________________________
Parent/Guardian #2 Work Telephone: _________________________Cell Telephone: ________________________
Does your child have health insurance? Y N (circle one)
Private or Public (circle one)
Health Insurance Company _____________________________________ Policy # __________________________
If you don’t have health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health care
(restrictions may apply). Please contact your school nurse for more information about these programs. All communications are confidential.
Name and grade of siblings in Melrose Schools: _______________________________________________________
Does your child attend a before or after school program or have a sitter? (Y / N) If yes, please provide the
contact name and telephone number: ________________________________________________________________
In case of an emergency or illness and we are unable to reach the contacts above, please list alternative contacts
who will assume responsibility and transportation:
Name: ______________________________ Relationship: _______________________ Telephone: _______________
Name: ______________________________ Relationship: _______________________ Telephone: _______________
Note: In case of an emergency, we will attempt to contact the parent/guardian before calling the student’s primary care provider
(physician). Your child will be transported by ambulance to an emergency care facility, if necessary.
Physician’s Name: ________________________________________ Telephone Number: ______________________
Dentist’s Name: __________________________________________ Telephone Number: ______________________
How often does your child visit the dentist? ____ once a year ____ twice a year ___ has never been to a dentist
List all medications that your child takes: ____________________________________________________________
I give the school nurse permission to administer the following when appropriate (circle the medications
that you agree with): Acetaminophen (Tylenol) / Diphenhydramine Hydrochloride (Benadryl) (insect
bites/stings) / Ibuprofen (grade 6-12 only) / Cough Drops (grades 5 & over)
Please circle all the following that apply to your child: History of Concussion – Yes/No How many? _____
Heart Condition
Diabetes
Asthma
Seizure Disorder
ADHD/ADD
Migraines
Depression
Freq. Ear Infections
Kidney Disease
Rheumatic Fever
Speech Problems (specify) __________________________________________________________________________
Hearing Problems (specify) _________________________________________________________________________
Vision Problems (specify) __________________________________________________________________________
Allergies (specify – food, environment, medication, insect) ______________________________________________
Other (specify) ____________________________________________________________________________________
I give permission to the school nurse to share this information relevant to my child’s health condition with appropriate
school personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my
child’s primary care physician for the purpose of referral, diagnosis and treatment.
Signature of Parent/Guardian: __________________________________________ Date: ___________________
Rev. 7/12
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