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Student emergency information

Student Emergency Information
Last Name ……………………………. First Name ……………………. Sex F M F F Birth Date ……………………. Home/Mailing Address …………………………………………………………………. Home Ph. ……………………. Primary E-Mail Address . Parent/Guardian 1 …………………………………………… Relationship ……………. Work Ph. ……………………… Address …………………………………………………………………………………………………………………………… Parent/Guardian 2 …………………………………………. Relationship ……………… Work Ph. ………………………. Address …………………………………………………………………………………………………………………………. Friend/Relative if parent is not available ……………………………………. Relationship …………. Ph. …………………. Allergies or Health Conditions ……………………………………………………………………………………………….… Medications …………………………………………………………………………………………….………………………. Doctor …………………….………… Ph. …………………. Dentist …………….………. Ph. ………………….……. Health Insurance Company ………………………………………………….…………………………………………………. In the event of an emergency or serious illness, I request that the school contact me. If unable to reach me, you may contact the designated person listed above, contact my child’s physician for instructions, or make whatever arrangements are necessary to ensure my child’s well-being. Signature Parent/Guardian ……………………………………………………………………. Date …………………………. Over-the-Counter Medication Consent Form
Your child will always receive a thorough assessment by the school nurse before an appropriate medication is offered. Please check below those medications that the nurse may give to your child: For headache and minor muscle pain:
F Check here if the nurse has your permission to give your child the medications you have checked above without calling you
first.
FCheck here if you always want to be called before your child is given any of the above over-the-counter medication.
F Check here if you DO NOT WISH for your child to receive any of the above over-the-counter medications.
For all over-the-counter or prescription medications, you must bring the medication to the school nurse in the original container.
You will be asked to sign a consent form. No medications will be given with phone consent only; state law now requires
written consent be on file. Please support our efforts to maintain a safe school-do not send medication with your child.

This signed form will serve as consent for the medications checked above only.

Signature/Parent Guardian ………………………………………………………………. Date ………………………………….

Source: http://www.profile.k12.nh.us/athletic/Forms/Student%20Emergency%20Information.pdf

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