Notification For Emergency Or Illness
Student Information-One form should be submitted for EVERY student.

If your child needs to take a prescription medication routinely at school, please pick up a form from the nurse's office and have your doctor fill it out.

Email address *
Last Name *
Your answer
First Name *
Your answer
DOB
MM
/
DD
/
YYYY
Allergies
Your answer
Other medical concerns
Your answer
Physician name & phone number
Your answer
Orthodontist name & phone number
Your answer
Hospital to be used in case of Emergency
Your answer
1st Emergency contact name *
Your answer
1st Emergency contact phone number *
Your answer
2nd Emergency contact name
Your answer
2nd Emergency contact phone number
Your answer
The Health Office keeps a list of Over the Counter medications on hand to dispense to students. Please select the medications you WOULD allow your child to have during school hours. *
Required
Please let us know of any other concerns you may have.
Your answer
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