EmailMe Form - Medical History and Emergency Information

Student's Name *

First Last

Grade

Birth Date

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Father's Name

First Last

Work/Cell Number

### - ### - ####

Mother's Name

First Last

Work/Cell Number

### - ### - ####

Is the child taking any medications on a regular basis such as Insulin, Dilantin, Ritalin, etc? *

Yes

No

If yes, please specify:

Does the child have a physical health problem of which the school staff should be aware? (This may include special diet, prescriptions, communicable diseases or physical limitation on normal activities.) *

Yes

No

If yes, please specify:

Has the child ever consulted a physician, or been referred to a hospital or clinic for social, emotional or psychological concerns? *

Yes

No

If yes, please specify:

Please specify allergies to foods, drugs, insect bites or anything else:

List any illnesses, accidents or other health problems not included above that required medical attention within the last 12 months or any special procedures that need to be followed at school:

I authorize a teacher or staff person at Grace Academy to administer a non-aspirin/non-ibuprofen pain reliever to my child if needed: *

Yes

No

1 / 2