Emergency Packet Form EMERGENCY PACKET Student Name(Required) First Last Birth Date(Required) MM slash DD slash YYYY Grade(Required)Pre – KK1234567Teacher(Required)Resides With(Required) Mother Father Other If other, please write in whoCustody papers on file, if applicable Custody papers on file, if applicable Mother/Guardian InformationName(Required) First Last Home Phone(Required)Birth Date(Required) MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code Cell Phone(Required)Employer(Required)Work Phone(Required)Father/Guardian InformationName(Required) First Last Home Phone(Required)Birth Date(Required) MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code Cell Phone(Required)Employer(Required)Work Phone(Required)Emergency Contact list (if parents/guardians cannot be reached)1st emergency contact's name(Required) First Last Home Phone number(Required)Cell Phone number(Required)Relationship to child(Required)2nd emergency contact's name(Required) First Last Home Phone number(Required)Cell Phone number(Required)Relationship to child(Required)Student Health InformationPlease check all medical diagnosis that CURRENTLY apply(Required) None ADHD Allergies Diabetes Seizures Asthma Other If other, please write in the medical diagnosis of:Student's Medications(Required) None Yes As Needed MedicinesDaily MedicinesAllergies(Required) No Allergies Food Medicines List all AllergiesIs Allergy(ies) life threatening?(Required) Yes No N/A Medical Insurance(Required) Yes No I give permission for my child to have the appropriate dose of Tylenol (Acetaminophen), Advil (Ibuprofen), an antacid or other over the counter medications (OTC) as determined by and at the discretion of the nurse.(Required) Yes No E-signature and consent(Required) By checking this box, I verify that all of the above information is correct. This information may be shared with school personnel on a “need to know” basis. Δ
