JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
LCHS Emergency Information Form
Please complete this emergency information form and submit it by September 18th.
It is important that you inform us of your child's medical problems. This information will be shared with the appropriate personnel for your child's safety. If medication is required during the school day, send the labeled container to school with written permission to administer. NOTE - STUDENTS ARE NOT PERMITTED TO CARRY MEDICINE IN SCHOOL WITHOUT EXPRESS PERMISSION FROM THEIR PHYSICIAN.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student Last Name
*
Your answer
Student First Name
*
Your answer
Sex
*
Female
Male
Birthdate:
MM
/
DD
/
YYYY
Father/Guardian Name:
Your answer
Father/Guardian Cell Phone:
Your answer
Father/Guardian Work Phone:
Your answer
Father/Guardian Home Phone:
Your answer
Mother/Guardian Name:
Your answer
Mother/Guardian Cell Phone:
Your answer
Mother/Guardian Work Phone:
Your answer
Child Resides With:
Mother
Father
Both
Guardian
Clear selection
Home Address-- Father ---(city, state, zip):
Your answer
Home Address Mother-- (city, state, zip):
Your answer
Medical Condition and Medication (Please included dosage and time):
Your answer
My child may receive Acetaminophen:
Yes
No
Clear selection
My child may receive Ibuprofen:
Yes
No
Clear selection
My child may receive tums:
Yes
No
Clear selection
My student has allergies:
Local
Anaphylatic
Other:
Please explain allergies:
Your answer
My child has permission to carry inhaler (If yes, Dr. note required):
Yes
No
Clear selection
My child has permission to carry epipen (If yes, Dr. note required):
Yes
No
Clear selection
Contact Lenses
Yes
No
Clear selection
Glasses
Yes
No
Clear selection
Family Doctor Name and Phone Number:
Your answer
Family Dentist Name and Phone Number:
Your answer
IN CASE OF EMERGENCY: If parents/guardians are not available, list two (2) person with transportation who will be available and willing to assume temporary care of your child. PERSON #1 (Name, Relationship, and Phone number)
Your answer
PERSON #2 (Name, Relationship, and Phone number)
Your answer
Medical Insurance Provider
Your answer
Medical Insurance Group Number:
Your answer
In the event of an emergency when I cannot be contacted, I the undersigned, hereby give my consent for my child to be taken to the hospital by the volunteer Medical Corps for emergency treatment. (Please type name and date below)
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Lansdale Catholic High School.
Report Abuse
Forms
