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Mt. Carmel Youth Info, Emergency Contact & Medical
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Student Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Address
*
Your answer
Student Phone Number
*
Your answer
Student Email
*
Your answer
Parent Email
*
Your answer
Parent Phone Number
*
Your answer
Alternate Parent Phone number
Your answer
Emergency Contact (non-parent)
*
Your answer
Emergency Contact (non-parent) Phone number
*
Your answer
Alternate Emergency contact (non-parent)
Your answer
Alternate Emergency contact (non-parent) Phone number
Your answer
Medical Conditions or Allergies to Medicines we Should Know About
Your answer
Medications/Prescriptions
Your answer
Blood Type (if known)
Your answer
Physician Name and Number
Your answer
Insurance (company name, phone number)
Your answer
Medications Student is Permitted to have
*
Advil
Tyleno
Benadryl (tablet)
Benadryl (topical)
Analgesic Cream Rub (topical, Aspirin free)
Anti-fungal powder
Dramamine (motion sickness), tablets
Chloraseptic, Lozenges
Cortaid (Hydrocortisone), topical
Imodium AD (liquid)
Imodium AD (tablet)
Latex
Cough Drops
Maalox, Tablets
Neosporin, topical
Sudafed, tablet
Required
Any other info we should know
Your answer
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