Emergency Medical Information
Emergency Contacts
Please fill out at least two emergency contacts for your family (usually mother and
father or guardian). A third is preferred, such as another relative or authorized
adult.
Family Name
Emergency Contact Name (A)
Relationship to Student
Emergency Phone Number 1
Emergency Phone Number 2
Emergency Contact Name (B)
Relationship to Student
Emergency Phone Number 1
Emergency Phone Number 2
Emergency Contact Name (C)
Relationship to Student
Emergency Phone Number 1
Emergency Phone Number 2
Family Address
City, State, Zip
Student Information
Please fill out the following for each child enrolled. Please include Social Security
Number (SSN) in case of emergency admittance to hospital.
Student Name 1
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 2
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 3
Student Birthday
Student’s SSN
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 4
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 5
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 6
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 7
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 8
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 9
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Student Name 10
Student’s SSN
Student Birthday
Student’s Current Medications
Student’s Drug Allergies
Student’s Food Allergies (please note
anaphylactic reactions)
Does the student need emergency
medication on site? (Inhaler, epi-pen,
etc.) If yes, please specify.
Other medical conditions
Insurance Information
Insurance Carrier and Plan Name
Policy Number
Group Number
Employer or Individual Primary
Insured
Employer or Individual Primary
Address
City, State Zip
Phone
Primary Insured Name
Primary Insured SSN
Dependents Covered
If you have additional plans for some dependents, please indicate below.
Insurance Carrier and Plan Name
Policy Number
Group Number
Employer or Individual Primary
Insured
Employer or Individual Primary
Address
City, State Zip
Phone
Primary Insured Name
Primary Insured SSN
Dependents Covered
Insurance Carrier and Plan Name
Policy Number
Group Number
Employer or Individual Primary
Insured
Employer or Individual Primary
Address
City, State Zip
Phone
Primary Insured Name
Primary Insured SSN
Dependents Covered
Consent for Emergency Care
This authorizes Regina Mater to give permission to
appropriate medical or hospital personnel to
provide emergency medical or surgical care for the
above dependents in the event that I cannot be
contacted immediately. I understand that a
conscientious effort will be made to locate the
named emergency contacts before any action will
be taken. I understand my obligation to Regina
Mater to keep contact info current. I will assume
the cost of medical or surgical care.
For temporary relief of minor ailments my child
may be given the following according to dosage
instructions:
Tylenol
Ibuprofen
Triple Antibiotic Cream
Benedryl
Benedryl Cream
Essential Oils