GRADE_____

EMERGENCY INFORMATION

**If there are changes to this information during the school year, please call the school to update.

STUDENT NAME _

PARENT/GUARDIAN _ _____ Phone – Home___________ Work_________________

Emergency contact if parent not available:

1._________________________________________________ Phone_______________

2.__________________________________________________Phone ______________

In the case of a medical emergency, I give district staff my permission to seek ~medical attention for my child at the nearest medical emergency

facility. I understand that I will be notified as soon as possible by

District staff.

**For the safety of the child, the health information on this form may be shared with staff who have a need to know.

PARENT SIGNATURE:______________________________________ DATE:___________

Does your child have any medical conditions which staff or medical

personnel should be aware of? YES_________ NO_________ If so, please

indicate your child’s medical conditions and list your child's usual

symptoms as well as the usual treatment.

None

If your child currently takes medication, please indicate the name of the medication as well as the dosage.

None

Please list any food or medication allergies which your child experiences, as well as your child's usual symptoms.

None

STUDENT’S DOCTOR: MEDICAL INSURANCE COMPANY:

Name______________________ Name_________________________

Address___________________ Policy Holder________________

Phone _______________ Policy Number________________