2023/24 Emergency Information/Authorization Record

Family Name

How many student are in your family?

Address

City

State/Province

Zip/Postal

Parent Info

Parent to call first

Mother's Name

Mother's Cell Phone

Mother's Employer

Mother's Work Phone

Father's Name

Father's Cell Phone

Father's Employeer

Father's Work Phone

Contact Persons in case of accident or illness, if parents are unavailable:

Emergency Contact #1: (First & Last Name)

Emergency Contact #1 Phone

Relationship

Emergency Contact #2: (First & Last Name)

Emergency Contact #2 Phone

Relationship

In case of emergency closing of school, which HR parents could release your child to:

Parent Release #1

Parent Release #2

Doctor / Hospital Information

Physician's Name

Physician's Phone

Dentist's Name

Dentist's Phone

Hospital Preference

PLEASE COMPLETE THE INFORMATION BELOW FOR EACH STUDENT IN YOUR FAMILY

Student 1 Information

Student 1 Name

Student 1 Grade

Student 1: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 1: Additional information for above medical conditions

Student 2 Information

Student 2 Name

Student 2 Grade

Student 2: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 2: Additional information for above medical conditions

Student 3 Information

Student 3 Name

Student 3 Grade

Student 3: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 3: Additional information for above medical conditions

Student 4 Information

Student 4 Name

Student 4 Grade

Student 4: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 4: Additional information for above medical conditions

Student 5 Information

Student 5 Name

Student 5 Grade

Student 5: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 5: Additional information for above medical conditions

Student 6 Information

Student 6 Name

Student 6 Grade

Student 6: This medication CANNOT be used on my child:

Antibiotic Ointment

Hydrocortisone Cream 1%

Calamine Lotion

Petroleum Jelly (used as lip balm)

This is a list of the external medications, which we use in the First Aid Room. If there is a medication listed here which CANNOT be used on your child, please put a check next to it.

Student 6: Additional information for above medical conditions

Parent Authorization and Agreement

I understand and Agree

In case of accident or serious illness, and we the people I designated are unable to be reached, I hereby authorize the school to call the physician listed and follow his instructions. If this physician is unable to be contacted, the school may make whatever arrangements are deemed necessary

Signature

Clear

Printed Name

Date