Student Information

Student 1 Health Information

The following medication(s) may be administered to my child, if needed (check all that apply):

Student 2 Health Information

Student 3 Health Information

The following medication(s) may be administered to my child, if needed (check all that apply):
Parent 1
Parent 2
Emergency Contacts
Please enter Name, Home Phone, Cell Phone of 3 contacts other than parentsWe will always call parents of students first.
Medical Contacts
Emergency Permissions
By providing my electronic signature I acknowledge that the school has permission, in case of an emergency when I cannot be reached, to take my child(ren) to the appropriate facility and the medical staff has my permission to provide treatment as needed.