Student Emergency Contact Form Page 2
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22013 – 2014 Student Emergency Contact Form
M
I
C
P
EDICAL
NFORMATION AND
ONSENT
AGE
STUDENT ______________________________________________________________
Last Name
First Name
Middle
MEDICAL HEALTH INFORMATION
Medication: Does your child require medication? (Circle one)
Yes
No
Do you give permission for your child to be administered:
Acetaminophen (Tylenol)
Yes
No
Ibuprofen
Yes
No
Non-prescription cough drops
Yes
No
Antihistamines (Benadryl, etc.)
Yes
No
Antacids (Tums, etc.)
Yes
No
If your child requires medication at school, all medication sent to the school must be in the original prescription container with a current date and the
child’s name. An “Authorization for Administration of Medication” form must be on file. Please list medications below:
Medication
Dosage
Hour(s) Given
Health Insurance Information: (Please circle the type of coverage you have.)
Would you like information about Dr. Dynasaur?
Yes
No
Family Health Insurance
Dr. Dynasaur
No Health Insurance
Health Plan/Group Name ____________________________________________________ Policy No. _________________
Date of last Well Child exam: ________________
Date of last dental checkup __________________
Physician/Health Care Provider _______________________________________________ Phone No. _________________
Dentist ___________________________________________________________________ Phone No. _________________
Vision and/or Hearing Problems: (Please circle all that apply.)
Glasses
Contacts
For reading
All the time
Date of last eye exam _________________
Eye Care Provider _______________________________ Phone No. _____________________
Does your child wear a hearing aid? _________
Which ears? ____________________________
Medical Conditions: (Please circle all that apply.)
Severe allergies requiring:
Epi-pen
Benadryl
Severe allergies: Food / Environmental
Stinging Insects / Bees
Medicines / Drugs
Other __________________________
Please explain all allergies listed above: ____________________________________________________________________________________
Current asthma?
Yes
No
Uses inhaler
On daily medication
Asthma action plan
Current seizures?
Yes
No
Diabetes?
Yes
No
Insulin dependent
Behavior problems: _______________________________________
Movement limitations: _________________________________________
Immunizations: ________________________________________________________________ Date Given ________________
Recent illness, hospitalization or surgery – dates and descriptions: _______________________________________________________________
Medical condition which might require care or accommodation at school: __________________________________________________________
E
T
A
MERGENCY
REATMENT
UTHORIZATION
In the event of an emergency, I request the school contact me, If they are not able to reach me and emergency care is considerer necessary, I give
permission to the school personnel to seek emergency medical care, including transportation to and care at the closest emergency facilities, and I
assume financial responsibility for such.
_________________________________________________
Signature of Parent or Guardian
C
P
R
ARE
ROVIDER
ELEASE
I give permission to the school nurse / guidance counselor / principal to contact my child’s medical or dental care providers for the purpose of sharing or
requesting pertinent information relating to my child’s health and care, or treatment received.
_________________________________________________
Signature of Parent or Guardian
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