HEALTH OFFICE EMERGENCY CONTACT INFORMATION
Student's LAST Name:_______________________FIRST Name__________________
Student's Address__________________________________________________________
Male/Female____D.O.B._______Place of Birth_________________________Grade___
Father's Name______________________Mother's Name___________________________
Address____________________________Address_________________________________
Please provide phone members in the order in which you wish to be called. Examples for phone types
would be Mom's cell, Dad's cell, Mom's work and Dad's Work.
Priority #1 Phone_______________________________Type Home Phone
Priority #2 Phone_______________________________Type___________________
Priority #3 Phone_______________________________Type___________________
Priority #4 Phone_______________________________Type___________________
Priority #5 Phone_______________________________Type___________________
Persons to contact if parents are unavailable(for emergencies only; parental permission is required for a student to go home ill):
Name___________________________________Name____________________________________
Address_________________________________Address_________________________________
Phone #_________________________________Phone #_________________________________
Emergency Information:
Family Physician and/or clinic Facility___________________________ My Child is______
Address________________________________ is not______
Phone__________________________________ covered by health insurance
Please note: All medications, including Advil and Tylenol, require written parental permission renewed annually.
Prescription medication must be sent in the original prescription bottle with a note from the prescribing doctor.
Special forms are required for Self-administration of emergency medications and Epi-Pens at school.
My son/daughter has the following medical problems, chronic disease, or allergies
___________________________________________________________________________
My son/daughter takes this following medication(s) on a regular basis:
___________________________________________________________________________
**Information regarding my child's medical history and or condition may be shared with school staff on a need to know basis
______________________________________ __________
Parent/Guardian Signature Date