LCHS Emergency Information Form-School year-2024-2025
Please complete this emergency information form for the 2024-2025 school year for each student attending LC and submit by September 13th.
It is important that you fill out this form in case of an emergency and inform us of any medical issues pertaining to your child.
This information will only be shared with the appropriate personnel for your child's safety.

If medication is required during the school day, please send the labeled container to school with written permission to administer. You may find the form on the LC website.

** NOTE - STUDENTS ARE NOT PERMITTED TO CARRY MEDICINE IN SCHOOL  WITHOUT EXPRESS PERMISSION FROM THEIR PHYSICIAN.
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Name
Student Last Name *
Student First Name *
Sex *
Birthdate:
MM
/
DD
/
YYYY
Father/Guardian Name:
Father/Guardian Cell Phone:
Father/Guardian Work Phone:
Father/Guardian Home Phone:
Mother/Guardian Name:
Mother/Guardian Cell Phone:
Mother/Guardian Work Phone:
Child Resides With:
Clear selection
Home Address-- Father ---(city, state, zip):
Home Address Mother-- (city, state, zip):
Medical Condition and Medication needed (Please included dosage and time):
My child may receive Acetaminophen:
Clear selection
My child may receive Ibuprofen:
Clear selection
My child may receive tums:
Clear selection
My student has allergies:
Please explain allergies:
My child has permission to carry inhaler (**If yes, Dr. note required-- Please send into the Nurse's Office):
Clear selection
My child has permission to carry epipen (**If yes, Dr. orders are required):
Clear selection
Contact Lenses
Clear selection
Glasses
Clear selection
Family Doctor Name and Phone Number:
Family Dentist Name and Phone Number:
IN CASE OF EMERGENCY: If parents/guardians are not available, list two (2) persons with transportation who will be available and willing to assume temporary care of your child. PERSON #1 (Name, Relationship, and Phone number)
 PERSON #2 (Name, Relationship, and Phone number)
Medical Insurance Provider
Medical Insurance Group Number:
In the event of an emergency when I cannot be contacted, I the undersigned, hereby give my consent for my child to be taken to the hospital by the volunteer Medical Corps for emergency treatment.  (Please type name and date below)
Submit
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