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Microsoft word - 02-2011 emergency care and health form.doc

__________________________________________________________________________________________________________________________ Student’s last name Father’s Name ________________________________________ Mother’s Name ________________________________________ Father’s Home Phone:________________________ Mother’s Home Phone: ________________________ Father’s Office Phone: ________________________ Mother’s Office Phone: ________________________ Father’s Mobile : _____________________________ Mother’s Mobile : _____________________________ Father’s occupation: __________________________________________ Mother’s occupation:___________________________________ Father’s E-mail ___________________________________________________ Mother’s Email ________________________________________ Person(s) To Call When Parents Cannot Be Reached / and who may pick up the child from school
Name _______________________________________________Relationship ______________________________Phone ____________________ Name _______________________________________________Relationship ______________________________Phone ____________________ Family Physician ______________________________________City ____________________________________Phone _____________________ Choice of Hospital ____________________________________Insurance Company___________________________________________________ Has child any drug/food/environmental/etc. allergies: ___________________________________________________________________________ Any additional medication information: _____________________________________________________________________________________ List daily medications: ____________________________________________________________ Date of last Tetanus shot __________________ If any emergency arises, the school will try to contact the student’s mother or father. If neither Parent can be reached, Dr. ______________________ has my permission to be wholly responsible for the care of my child. If he is unavailable in the event of a major emergency, the administration is directed to seek emergency care at the medical or hospital facility indicated above. I will be responsible for the payment of all expenses incurred. __________________________________________ STUDENT HEALTH FORM

MAY / MAY NOT have TYLENOL 500mg as needed.
MAY / MAY NOT have HYDROCORTISONE CREAM 1% as needed.
MAY / MAY NOT have IBUPROFEN 200-400 mg as needed.
MAY / MAY NOT have CALAMINE LOTION or BENADRYL TOPICAL as
MAY / MAY NOT have BENADRYL 25mg as needed.
MAY / MAY NOT have NEOSPORINE TRIPLE ANTIBIOTIC as needed.
MAY / MAY NOT have TUMS chewable Tablet as needed.
MAY / MAY NOT have ___________________________________ as needed. MAY / MAY NOT have HALLS COUGH DROPS as needed.

List any drug / food / environmental / etc. allergies:

______________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________ _____________________________________________________________ __________________ Parent / Guardian Signature

Source: http://www.ignatiusofloyola.org/docs/04-2011%20emergency%20care%20and%20health%20form.pdf

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