Confidential Emergency Information Park Maitland School 2018-2019
On this form, you will be filling out a two-page health information section for your child. It may be helpful to gather health insurance information, doctor and dentist contact information, and emergency contact numbers before you begin. If you have more than one child press the submit button at the end of the form and then select submit another form when prompted. Thank you!
Email address *
Student Grade Level: *
Student last name: *
Your answer
Student first name: *
Your answer
Parent #1 first and last name: *
Your answer
Parent #1 cell phone number: *
Your answer
Parent #1 alternate phone number: *
Your answer
Parent #2 first and last name: *
Your answer
Parent #2 cell phone number: *
Your answer
Parent #2 alternate phone number: *
Your answer
In the event that we cannot reach either parent, please list two contact names and numbers. *
Your answer
Physician name and phone number : *
Your answer
Dentist name and phone number : *
Your answer
Medical insurance provider: *
Your answer
Policy number: *
Your answer
Group number: *
Your answer
Insurance preferred hospital: (Responding medical unit will make final determination as to appropriate facility for the emergency.) *
Your answer
Medical Information
List all current medications with time taken. (If no medications please type "None"). *
Your answer
List all known allergies. Please be specific and include if the allergies are ingested, airborne, facility processing/traces, etc. (If no allergies please type "None"). *
Your answer
Will you be providing an epipen for your child? *
Existing medical conditions, history, previous surgeries, and chronic conditions. (If no medical conditions please type "None"). *
Your answer
I hereby give consent for the above named child to be included in Park Maitland's clinic services while at school or on field trips. This may involve being given "over the counter" medications as appropriate to enable him/her to remain at school. I understand that in the event of a fever or obvious illness the nurse will contact me. If you have any further questions please contact the nurse. *
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