MEDICAL EMERGENCY INFORMATION FORM

SSFHS GRAD NIGHT MAY 30, 2014
MEDICAL EMERGENCY INFORMATION

Name of Attendee                                                                  Birth Date                           

Name of Parent/Guardian                                                                                                             

Address                                                                                                                                            

Parent/Guardian Home Phone                                          Cell Phone                                      

Person to contact if parent/guardian is not available

Name                                                             Relationship                                                        

Home Phone                                                  Cell Phone                                                  

Contacts in case of injury or illness (must be filled out completely):

Name of Physician                                                                                                                         

Phone                                                 Address                                                                        

Insurance Provider AND Policy #                                                                                                            

Name of Dentist/Orthodontist                                                                                                       

Phone                                                 Address                                                                          

Name of Eye Doctor                                                                                                                       

Phone                                                 Address                                                                        

Please list medications and dosage student currently (or routinely) takes:

                                                                                                                                                           

Does student need to take/administer any medication(s) during Grad Night 2014? If yes, please list those medications and dosage amounts:                                                                                                         

Please list any allergies (medication or Other):                                                                           _______________________         

In the event you cannot be reached, do you give permission for us to obtain the necessary medical aid, including ambulance service if needed, at YOUR expense:  Yes                     
No                

If NO , what would you like us to do?

                                                                                                                                                           

                                                                                                                                                           

Signature of parent/guardian                                                                 Date                            

Printed name of parent/guardian