PAMDS Emergency Contact Form Summer 2021
It is important that we can reach you, or someone who can advocate for your child on your behalf, at all times. Please make sure to contact us if any information changes so that we can update our records accordingly.
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Email *
Child's Name *
Child's Date of Birth *
MM
/
DD
/
YYYY
Address (Street, Apartment #, City, State, Zip) *
Home Phone Number
Allergies *
Does your child have an EpiPen? (If yes, bring an EpiPen for your child to keep at school AND have your child's doctor provide the school with an "Allergy Action Plan") *
Parent 1 Name *
Parent 1 Cell Number *
Parent 1 Business Phone Number
Parent 1 Email Address *
Parent 2 Name
Parent 2 Cell Number
Parent 2 Business Number
Parent 2 Email Address
Child's Pediatrician Name *
Pediatrician Phone Number *
Caregiver's Name
Caregiver's Phone Number
Emergency Contact Name (In case we are unable to reach either parent or caregiver) *
Emergency Contact Relationship to Child *
Emergency Contact Phone Number *
The Department of Health requires that we have consent for emergency medical treatment for each child enrolled in the school. The Department of Health also mandates that if a child is showing symptoms of anaphylaxis, the school must treat the child with an Epinephrine Auto-Injector even if the child does not have a prescription or any known allergies. Please sign below indicating your consent for us to transport your child to a hospital and/or use an Epinephrine Auto-Injector in the event of a medical emergency. In any event, the school will call 911 and notify the child’s family.
I hereby authorize PAMDS staff to obtain necessary emergency medical treatment for my child, including using an Epinephrine Auto-Injector if my child is showing signs of anaphylaxis, with the understanding that the family will be notified as soon as possible. (Sign name below.) *
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