Notification For Emergency Or Illness

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Student Information-One form should be submitted for EVERY student.

If your child needs to take a prescription medication routinely at school, please pick up a form from the nurse's office and have your doctor fill it out.

Email *

Last Name *

First Name *

DOB

YYYY

Allergies

Other medical concerns

Physician name & phone number

Orthodontist name & phone number

Hospital to be used in case of Emergency

1st Emergency contact name *

1st Emergency contact phone number *

2nd Emergency contact name

2nd Emergency contact phone number

The Health Office keeps a list of Over the Counter medications on hand to dispense to students. Please select the medications you WOULD allow your child to have during school hours. *

Tylenol

Ibuprofen (Motrin)

Tums

Cough Drops/Chloraseptic Spray

Dimetapp/Triaminic

Benadryl

Other:

Required

Please let us know of any other concerns you may have.

Send me a copy of my responses.

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