STUDENT HEALTH AND EMERGENCY INFORMATION FORM
Does your child have health insurance?
Health Insurance Company
Authorized adults for emergency
Please indicate names of others who will assume responsibility and provide transportation for your student in case of illness/injury/emergency evacuation:
Relationship to student
In case of medical emergency, the school will attempt to contact parent/guardian before calling student's primary care provider. Your child will be transported by ambulance to an emergency care facility if necessary.
My preference if to have my child treated at the following medical facility, if possible:
Please list all medications that your child takes:
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