Medical Information
Insurance
Information:
_________________________________________________________
Policy #: ____________________
Date of Last
Tetanus Shot: ______/______/______
Additional
Comments:
_________________________________________________________________
____________________________________________________________________________________
Check any
physical disorder that would affect your child’s normal progress in a
classroom situation:
Asthma
Diabetes
Epilepsy
Hemophilia
Other, please explain below:
____________________________________________________________________________________
Does your
son/daughter take daily medication?
No
Yes, please list:
_______________________________________________________________________________________________________________
Does your
son/daughter have allergies?
No
Yes,
Allergic to:
please list:
____________________________________________________________________________________
Family Doctor:
_______________________________________________________ Phone: (
) ___________ - ______________
Hospital of
your choice in the event an emergency calls for immediate attention and no
one listed on the
_________________________________________________
“I agree to pay
any/all charges which may become necessary during any emergency treatment
and/or pay
any/all
hospital charges if my child must be taken to the hospital should the school
be unable to locate me
or the listed
contacts by telephone at the time of said emergency.”
Signature of
Parent / Guardian:
______________________________________________________________
Date: ______/______/______