Student 1 Health Information

Please note that the State of Pennsylvania requires that the school have a form from the physician giving the child's allergy or asthma plan and school treatment protocol. Please contact T. Claire.
The following medication(s) may be administered to my child, if needed (check all that apply):
If you chose "Other" above, please explain:​

Student 2 Health Information

Please note that the State of Pennsylvania requires that the school have a form from the physician giving the child's allergy or asthma plan and school treatment protocol. Please contact T. Claire.
The following medication(s) may be administered to my child, if needed (check all that apply):
If you chose "Other" above, please explain:​​

Student 3 Health Information

Please note that the State of Pennsylvania requires that the school have a form from the physician giving the child's allergy or asthma plan and school treatment protocol. Please contact T. Claire.
The following medication(s) may be administered to my child, if needed (check all that apply):
If you chose "Other" above, please explain:​​

Parent/Guardian 1

Parent/Guardian 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.