Emergency Information
Email address *
Student's Name: *
Your answer
Parent Name & Contact Number *
Your answer
I. Health Information
1. Does the applicant have any allergies? (food, medication, etc.) *
2. Does the applicant have asthma? *
3. Does the applicant have special health care needs? *
4. Does the applicant take medication for any condition or illness? *
5. Please provide any additional health information details: *
Your answer
II. Consent for emergency medical treatment
In the event of a medical emergency, I hereby give consent for necessary emergency medical treatment for my child to be obtained, with the understanding that I will be notified as soon as possible. I understand that every effort will be made to contact me, or, if I am unavailable, the emergency contact(s) listed., before and after medical care is provided *
III. Emergency Contact information:
Emergency Contact Name & Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
IV. Pick up/ Dismissal:
Our dismissal policy is that we DO NOT dismiss any student under 15, unless the parents confirm that they can leave on their own. All parents/guardians must come into the lobby on Queens Hall to pick up the child(ren). We do not even allow the children to leave the building without their parent. Please confirm if your child is allowed to leave on their own
A copy of your responses will be emailed to the address you provided.
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