EmailMe Form - Medical Release & Emergency Contact Form

Student Last Name *
Student First Name *
Grade Level *
(please enter numeric values only and enter 0 for Kindergarten)
Birthdate *
MM / DD / YYYY
Mother's Name
First Last
Mother's Daytime Number
### - ### - ####
Father's Name
First Last
Father's Daytime Number
### - ### - ####
Primary Parent Email *
Emergency Contact (other than parents) *
First Last
Emergency Contact Number *
### - ### - ####
Do we have permission to administer the following?
Please check all that are allowed.
Tylenol
Ibuprofen
Benedryl
Tums
Cough Drops
Emergency Medical Information
Please check all that apply
Allergies (list below)
Have an epipen?
Asthma
Diabetes
Please list any allergies or medications that we should be aware of. Please let us know if an allergy is severe so we can monitor appropriately and be aware for class parties, etc.
Please list any additional pertinent information we may need in the case of an emergency.
To the best of my knowledge, everything on this form is accurate.
Electronic Signature