Grad Night Emergency Medical Form

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Please complete this form for each student who will be attending Grad Night 2024 at Universal Studios. The deadline to submit this form is May 10, 2024. Please complete one form per student and send from parent/guardian email.

𝘼 𝙘𝙤𝙥𝙮 𝙤𝙛 𝙮𝙤𝙪𝙧 𝙧𝙚𝙨𝙥𝙤𝙣𝙨𝙚𝙨 𝙬𝙞𝙡𝙡 𝙗𝙚 𝙚𝙢𝙖𝙞𝙡𝙚𝙙 𝙩𝙤 𝙮𝙤𝙪. 𝙏𝙝𝙚 𝙚-𝙢𝙖𝙞𝙡 𝙮𝙤𝙪 𝙚𝙣𝙩𝙚𝙧 𝙗𝙚𝙡𝙤𝙬 𝙞𝙨 𝙩𝙝𝙚 𝙖𝙙𝙙𝙧𝙚𝙨𝙨 𝙩𝙝𝙚 𝙙𝙤𝙘𝙪𝙢𝙚𝙣𝙩 𝙬𝙞𝙡𝙡 𝙗𝙚 𝙨𝙚𝙣𝙩 𝙖𝙣𝙙 𝙧𝙚𝙘𝙤𝙧𝙙𝙚𝙙 𝙖𝙨 𝙩𝙝𝙚 𝙥𝙖𝙧𝙚𝙣𝙩'𝙨 𝙘𝙤𝙣𝙩𝙖𝙘𝙩 𝙚-𝙢𝙖𝙞𝙡.

Email *

Student First Name *

First name

Student Last Name *

Last name

Student Email *

Student Birth Date *

YYYY

Parent First Name *

Parent or guardian first name

Parent Last Name *

Parent or guardian last name

Parent Primary Phone number *

Parent or guardian primary contact number. Cell phone preferred. This number will be used by the NAME to contact the parent. Please enter in ###-###-#### format.

Parent Secondary Phone number *

Parent or guardian secondary contact number. Please enter in ###-###-#### format.

Parent Address *

Parent or guardian street address, city, zip (max 100 characters)

Name Emergency Contact #1 *

Full name of emergency contact #1 if above contact cannot be reached.

Phone Emergency Contact #1 * *

Phone number of emergency contact#1, ###-###-#### format.

Relationship Emergency Contact #1 *

Relationship of the emergency contact #1 person to the student.

Parent/Guardian

Grandparent

Sibling

Other Relative

Family Friend

Other:

Name Emergency Contact #2

Full name of second emergency contact #2 if above contact #1 cannot be reached.

Phone Emergency Contact #2

Phone number of emergency contact #2, ###-###-#### format.

Relationship Emergency Contact #2

Relationship of the emergency contact #2 person to the student.

Parent/Guardian

Grandparent

Sibling

Other Relative

Family Friend

Other:

Clear selection

Doctor Name *

Name of student's medical doctor.

Doctor Phone Number *

###-###-#### format.

Medical Insurance Company *

Health insurance company name, if any

Medical Insurance Group Number *

Insurance group number.

Medical Insurance ID Number *

Insurance ID number.

Medical Insurance Phone Number *

Insurance phone number, in ###-###-#### format.

Medical Emergency Directive *

In the event you cannot be reached, do you give permission for the school to obtain the necessary medical aid, including ambulance service if needed, at your expense?

Yes

Medicine *

Please list prescription medications and over the counter medications (including epi-pens and inhalers) that the student takes on a regular basis. Please include the name, dosage, and frequency for each medication. 𝙎𝙩𝙪𝙙𝙚𝙣𝙩𝙨 𝙬𝙞𝙩𝙝 𝙥𝙧𝙚𝙨𝙘𝙧𝙞𝙥𝙩𝙞𝙤𝙣 𝙢𝙚𝙙𝙞𝙘𝙖𝙩𝙞𝙤𝙣 𝙬𝙞𝙡𝙡 𝙗𝙚 𝙧𝙚𝙨𝙥𝙤𝙣𝙨𝙞𝙗𝙡𝙚 𝙛𝙤𝙧 𝙩𝙝𝙚𝙞𝙧 𝙤𝙬𝙣 𝙢𝙚𝙙𝙞𝙘𝙖𝙩𝙞𝙤𝙣 𝙤𝙣 𝙩𝙝𝙞𝙨 𝙩𝙧𝙞𝙥. 𝘼𝙡𝙡 𝙥𝙧𝙚𝙨𝙘𝙧𝙞𝙥𝙩𝙞𝙤𝙣 𝙢𝙚𝙙𝙞𝙘𝙖𝙩𝙞𝙤𝙣, 𝙞𝙣𝙘𝙡𝙪𝙙𝙞𝙣𝙜 𝙚𝙥𝙞-𝙥𝙚𝙣𝙨 𝙖𝙣𝙙 𝙞𝙣𝙝𝙖𝙡𝙚𝙧𝙨, 𝙢𝙪𝙨𝙩 𝙘𝙤𝙣𝙩𝙖𝙞𝙣 𝙖 𝙘𝙪𝙧𝙧𝙚𝙣𝙩 𝙥𝙧𝙚𝙨𝙘𝙧𝙞𝙥𝙩𝙞𝙤𝙣 𝙡𝙖𝙗𝙚𝙡 𝙬𝙞𝙩𝙝 𝙩𝙝𝙚 𝙨𝙩𝙪𝙙𝙚𝙣𝙩'𝙨 𝙣𝙖𝙢𝙚 𝙤𝙣 𝙞𝙩.

Medical History

Please share any other information we should know about your student's medical history.

Allergies *

Please select any allergy categories your student may have (ok to select one or both categories). If no known allergies, please check "None". If you check any boxes other than "None", please elaborate in the appropriate sections below.

Medicine

Food/Other

None

Other:

Required

Medicine Allergies

If you checked "Medicine" in the above Allergies question, please elaborate (max 100 characters. If you need more space, please manually write on form after it's printed out).

Misc Allergies

If you checked "Food/Other" box in the above Allergies question, please elaborate (max 100 Characters. if you need more space, please manually write on form after it's printed out).

Confirmation *

You understand and agree that your electronic consent is your electronic signature which specifically constitutes that you (and your child) have read, understood, filled out your student's medical information to the best of your knowledge. Please make copies for your records, and feel free to reach out to millshighgradnight@gmail.com with any questions or concerns. Thank you for submitting this form.

I Understand

Required

Student Electronic Signature *

Parent Electronic Signature *

Parent/guardian signature required for all students, even over 18.

A copy of your responses will be emailed to the address you provided.

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