MASCONOMET REGIONAL SCHOOL DISTRICT

EMERGENCY INFORMATION

Please complete the emergency information listed below (please print) in order for us to keep this information on file for your child. Return this form to the school nurse. Complete custodial parent section if applicable.

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STUDENT’S LAST NAME FIRST MIDDLE SEX DOB GRADE

____________________________________________________________________________Y N_______

STUDENT’S HOME ADDRESS TELEPHONE UNLISTED

_______________________YES[]NO[]________________________________________ Y N_______

PARENT/GUARDIAN CUSTODIAL ADDRESS TELEPHONE UNLISTED

_______________________YES[]NO[]__________________________________________ Y N_______

PARENT/GUARDIAN CUSTODIAL ADDRESS TELEPHONE UNLISTED

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PARENT/GUARDIAN PLACE OF EMPLOYMENT/TELEPHONE PAGER/CELL

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PARENT/GUARDIAN PLACE OF EMPLOYMENT/TELEPHONE PAGER/CELL

In the event of an emergency, medical treatment (including transportation to the hospital) will be initiated immediately. The following information is requested, in case a parent cannot be reached.

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PHYSICIAN TELEPHONE

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HOSPITAL TELEPHONE

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INSURANCE PROVIDER INSURANCE SUBSCRIBER NUMBER (OPTIONAL)

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DENTIST TELEPHONE

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EMERGENCY CONTACT 1 CITY/TOWN TELEPHONE

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EMERGENCY CONTACT 2 CITY/TOWN TELEPHONE

To better serve your child's physical/emotional/social health needs, check all the following that apply:

__ Diabetes __Seizures __ADD __ADHD __Migraines __Depression __Anxiety __Asthma

__Allergies; to what________________________________________________________________________

__other conditions; specify___________________________________________________________________

Please list all the medications your child takes_____________________________________________________

PERMISSION TO GIVE THE FOLLOWING OVER THE COUNTER MEDICATIONS: [ ] Y [ ] N

Acetaminophen (Tylenol), Bacitracin Ointment, Cepacol Lozenges, Diphenhydramine (Benadryl), Ibuprofen (Advil), Anbesol, Calamine Lotion, Cough Drops, Hydrocortisone Cream, Tums

I understand that this information is confidential. However, federal law permits information in the school health record to be shared with school officials on a "need to know basis" and with a very limited number of other person, including those who could help in an emergency. In other circumstances, my consent wil be required.

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DATE PARENT/GUARDIAN SIGNATURE EMAIL ADDRESS

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DATE STUDENT SIGNATURE