PARENT/GUARDIAN INFORMATION
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ABC School EMERGENCY & MEDICAL FORM
School Year: 2020-21
STUDENT INFORMATION To be completed by Parent/Guardian only. Use Pen to fill out information.
____________________________________________ _____________________________________________________ _____________ _______________________________
Last Name Student’s Legal First Name MI Nickname
____________________________________________ ______________________________________ _______________ _____________ _______________________________
Homeroom Teacher/First Period Birth Date Age Grade Sex/Race
____________________________________________________________________________________________________________________________________________________________________________________________
Mailing Address
____________________________________________________________________________________________________________________________________________________________________________________________
Resident Address (If different)
Parent/Guardian Name Place of Employment Phone (H) Phone (W) Phone (C)
Parent/Guardian Name Place of Employment Phone (H) Phone (W) Phone (C)
STUDENT LIVES WITH: ☐ Both Parents (same address) ☐ Mother ☐ Father ☐ Other
CUSTODY: __________________________________________________________________________________________________
(List any special custody arrangements. Appropriate legal documentation must be on file in a student’s cumulative folder)
RELIGIOUS RESTRICTIONS/SPECIFY: ___________________________________________________________________________
STUDENT HEALTH CONDITIONS/INSURANCE/DOCTOR INFORMATION
***It is important that you provide information regarding your child’s health conditions and health insurance. This
information will assist us in the case of an emergency.
Doctor’s Name
Address
Phone Number
STUDENT HEALTH INSURANCE
☐ Healthy Kids Acct #
☐ Medicaid ID #
Children’s Medical Services: ☐ Yes ☐ No If yes, name of case manager:
STUDENT HEALTH CONDITIONS
☐ Allergy to insects-
specify severity below
☐ Heart Disease/Murmur-
specify below
☐ Asthma-requiring
treatment at school
☐ Transplant- specify below
☐ Allergy to medicine -specify severity
below
☐ Psychological
Problems-specify below
☐ Diabetes (Type )
☐ Ear Infection/Repeated
☐ Allergy to food –
specify severity below
☐ Epilepsy/Seizures
(date of last seizure)
☐ Hypoglycemia
☐ Visual Problems-
specify below
☐ Cancer - specify below
☐ High blood pressure
☐ Drug Dependency
☐ Visual Correction Glasses
☐ Hernia – specify below
☐ Anemia
☐ Hyperactivity (ADD;
ADHD)
☐ Visual Correction Contacts
☐ Cerebral Palsy
☐ Sickle Cell disease
☐ Urological Conditions
☐ Hearing Impairment
☐ Scoliosis
☐ Sickle Cell trait
☐ Gastrointestinal
Condition
☐ Speech Impairment
☐ EpiPen
☐ Arthritis
☐ Kidney Disease
☐ Motor Impairment
☐ Headache
☐ Leukemia
☐ Muscular Dystrophy
☐ Hemophilia
☐ Nosebleeds
☐ Physical Impairment
☐ Pregnancy
☐ Other -specify below
Specify severity of health conditions/Specify restrictions on activity and any accommodations needed while at school:
________________________________________________________________________________________________________________________________________________________________
List all medications (prescription and non-prescription, including “as needed” and emergency meds) that student takes AT HOME OR SCHOOL: