Confidential Emergency Health Information Park Maitland School 2020-2021
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: *
Student first name: *
Parent #1 first and last name (This is the parent that we will call first): *
Parent #1 cell phone number (This is the parent that we will call first): *
Parent #1 alternate phone number: *
Parent #2 first and last name: *
Parent #2 cell phone number: *
Parent #2 alternate phone number: *
In the event that we cannot reach either parent, please list two contact names and numbers. *
Physician name and phone number : *
Dentist name and phone number : *
Medical insurance provider: *
Policy number: *
Group number: *
Insurance preferred hospital: (Responding medical unit will make final determination as to appropriate facility for the emergency.) *
Medical Information
List all current medications with time taken. (If no medications please type "None"). *
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"). *
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"). *
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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