HEALTH AND EMERGENCY INFORMATION FORM
Please fill out a separate form for each child.
Student’s full name *
First, middle, last
Your answer
Does your child suffer from any allergies?
Food, medication, insect bites etc.
Your answer
Does your child have any medical conditions we should know about?
Your answer
Is there any other information you would like to share about your child?
Special needs, behavior, etc.
Your answer
Emergency contact information.
List up to three people other than parents/guardians (Use the following format: Name - Phone Number - Relationship to student)
Your answer
Parent/Guardian - Type your name *
Consent for Emergency Medical Assistance. If at any point my child requires urgent medical treatment while at the Czech and Slovak School of North Carolina and if I or the emergency contact listed above cannot be contacted personally, I hereby give permission to the doctor, surgeon or designated person to make any decision that may prove necessary and to the Czech and Slovak School of North Carolina to disclose necessary medical information in order to do so.
Your answer
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