Emergency Medical Concern Form 2022-2023

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This form should be filled out ONLY for children who have emergency medical needs, i.e. allergies, seizures, asthma, etc.

The information you provide in this form will be posted in our main office and staff room.

If your child’s medical needs require additional planning on the part of the Netivot administration and staff, above and beyond carrying an Epi Pen or having one in the office, please contact Daniella: dpatini@netivot.com

IMPORTANT: If you are filling out this form, you MUST email a photo of your child(ren) to netivotfrontoffice@netivot.com

Email *

Student Last Name *

Student First Name *

Student Grade *

Reason for Medical Alert *

What to Look For? *

What to Do? *

Please Check All That Apply

Child is Anaphylactic

Child uses an Epi-Pen

Does your child carry his/her Epi-Pen with him/her at all times?

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