STUDENT CONTACT/MEDICAL INFORMATION
Student’s Name
Parent's Name
Home Address
Home Phone
Parent's Cell Phone(s)
In case of emergency, please notify:
Emergency Contact Name
Emergency Contact Phone
Permission is given to administer pain reliever (Advil, Ibuprofin, etc.) to my son/daughter
Permission is
not
given to administer pain reliever (Advil, Ibuprofin, etc.) to my son/daughter
Please list any allergies you would like for us to be aware of:
(Providing health insurance information is optional)
Health Insurance
Policy Number
If any of the contact information above changes, please notify a director so that the student’s file can be updated.
By signing below it is understood that the information above is correct, and that the information in the manual has been discussed and understood.
__________________________________________
Signature of Parent or Guardian
