Medical Alert Form School District No. 43, Coquitlam School Board Page 2
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5SCHOOL DISTRICT #43 (COQUITLAM)
MEDICAL ALERT FORM
Medical Alert Form
SCHOOL YEAR:
Last Name:
First Name:
Photo ID
Division:
(Parents do not send
photo unless requested)
Grade:
Birth Date:
Care Card #
Contact Name & Telephone Numbers
Mother/Guardian
Father/Guardian
Last Name:
Last Name:
Mother/Guardian
Father/Guardian
First Name:
First Name:
Mother/Guardian’s
Father/Guardian’s
Home Phone#
Work or Cell
Work or Cell
Physician Name
Telephone Number
emergency
Indicate what medical condition this student has that may require
care at school:
Describe the potential problem (include symptoms that might be observed):
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