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Religious School Emergency Information Form
Last Name of Parent
*
Last
Child 1:
*
Date of Birth
*
MM slash DD slash YYYY
Food or Drug Allergies? Special Medical Conditions? Check ALL that apply.
*
FOOD ALLERGIES
DRUG ALLERGIES
Special Medical Conditions
Prescription Medications
Food Allergies - List/Explain Allergies
*
Drug Allergies - List/Explain Allergies
*
Special Medical Conditions - List/Explain
*
Prescription Medications - List
*
Child 2:
Date of Birth
MM slash DD slash YYYY
Child 2: Food or Drug Allergies? Special Medical Conditions? Check ALL that apply.
FOOD ALLERGIES
DRUG ALLERGIES
Special Medical Conditions
Prescription Medications
Food Allergies - List/Explain Allergies
*
Drug Allergies - List/Explain Allergies
*
Special Medical Conditions - List/Explain
*
Prescription Medications - List
*
Child 3:
Date of Birth
MM slash DD slash YYYY
Child 3: Food or Drug Allergies? Special Medical Conditions? Check ALL that apply.
FOOD ALLERGIES
DRUG ALLERGIES
Special Medical Conditions
Prescription Medications
Food Allergies - List/Explain Allergies
*
Drug Allergies - List/Explain Allergies
*
Special Medical Conditions - List/Explain
*
Prescription Medications - List
*
Contact Information
Parent 1
*
Parent 2
Cell Phone 1
*
Cell Phone 2
Home Phone
Work Phone
Street Address
City/ Zip Code
Emergency Contact if parents cannot be reached. (911 will be called if life threating.)
Contact Name
*
Cell Phone
*
Alternate Phone
Doctor
Phone
Prefered Hospital
Any other relevant information:
Realizing that sudden illness or an accident may happen to a student, I hereby ask the school authorities to use their best judgment in such cases in caring for my child. It is understood that an earnest effort will be made to contact the parents, guardian, doctor and if necessary, the hospital named on this form.Ambulance service may also be provided. I further understand that the school is not responsible for any expense incurred.
Signature of Parent or Guardian
Date
MM slash DD slash YYYY
Δ
