Universal Medical information/Emergency Contact Release and Consent Form
School Year
Name of Student
(Last, First, Middle)
Grade
Teacher Name
Student Address:
Street
City
State
Zip
Home Telephone
Siblings at school
Name
Grade
Teacher
Siblings at school
Name
Grade
Teacher
Student Lives With
(Check all that apply)
Father or Legal Guardian's Information
Name
(Last, First)
Home Address (If different from child's)
Street
City
State
Zip
Home Phone
(If different from child's)
Work telephone
Mobile phone
Mother or Legal Guardian's Information
Name
(Last, First)
Home Address (If different from child's)
Street
City
State
Zip
Home Phone
(If different from child's)
Work telephone
Mobile phone
Emergency Contacts
Name and Address
Telephone Number (s)
Emergency Contacts
Name and Address
Telephone Number (s)
Emergency Contacts
Name and Address
Telephone Number (s)
Emergency Contacts
Name and Address
Telephone Number (s)
Student Medical Information
Primary Physician Name
Address
Telephone
Student Medical Information
Emergency Physician Name
Address
Telephone
Medical Conditions
(e.g. diabetes, epilepsy, heart conditions, etc.)
Disabilities
Allergies
(e.g. hay fever, strawberries, peanuts, etc.)
Medications
Allergies to Medication
Medicines to be Self-Administered by the Child
(See Below)
Dosage
Frequency
Medicines to be Administered by the School
(IF parents/guardians and school both agree that school shall do so; see below)
Dosage
By checking here you agree that all the above is true *
Required
Name
Relationship to Child
Date Signed
MM
/
DD
/
YYYY
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