Student Information

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Student Information

Please complete this health and emergency contact form.

Student First and Last Name *

Known Allergies Including Medications (Please include OTC medications if known) (If none, please state) *

Are there any medications staff need on hand for your child? (Epi-pen, inhaler, benadryl, etc.) *

Do you give staff permission to provide your student with basic over-the-counter medication (Ibuprofen, Tylenol, Tums, Pepto-Bismol) if needed?

Yes

Please contact Parent/Guardian prior to dispensing medication for approval

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Any Injuries or Medical Conditions Staff should be informed of? (Diabetes, Asthma, POTS, scoliosis, depression, etc.) If none, please state. *

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