LEVERETT ELEMENTARY SCHOOL
EMERGENCY INFORMATION
PLEASE COMPLETE ONE FORM FOR EACH CHILD
____________________________ ___________ _______________________________________ _______
Student’ s Name D.O.B. Address Grade
I give permission to the school nurse to share information relevant to my child’s health condition with appropriate
school personnel when needed to meet my child’s health and safety needs. I give permission to exchange
information with my child’s primary care physician for the purpose of referral, diagnosis and treatment.
In the event of a serious accident/illness involving my child while attending school, I hereby authorize the principal or
the principal’s designee to call one of the following physicians.
1st Choice:_________________________________ Phone:_______________________
2nd Choice:________________________________ Phone:_______________________
Dentist: ___________________________________ Phone:_______________________
Health Insurance: _______________________________________________________________________
If you do not have health insurance, Massachusetts has health insurance plans that will provide uninsured
children with affordable health care (restrictions may apply). Please contact the school nurse for more
information about these programs. All communications will be confidential.
List any medications regularly taken by child: _____________________________________________
List any allergies (food, drug, insects, etc): _______________________________________________
Parents are responsible for transportation when necessary during school hours.
Parent Names:_____________________________ _____________________________
Home Phone: _____________________________ _____________________________
Work Phone: ______________________________ _____________________________
Cell Phone: _______________________________ _____________________________
Email Address:_____________________________ _____________________________
If my child becomes ill while attending school and neither parent can be reached, you are authorized to call one of the
following alternates who has my permission to provide transportation for my child if necessary.
1st Choice:_________________________________ Phone: _______________________
2nd Choice:________________________________ Phone: _______________________
In case of emergency your child will be taken to the nearest medical facility. I hereby give my permission to the
hospital, medical facility, or physician to provide emergency care. I do understand that every attempt shall be made
to contact me as soon as possible.
________________________________________ _____________________________________ ____________
Parent/Guardian Signatures Date