SSFHS GRAD NIGHT 2014 MEDICAL EMERGENCY INFORMATON

SSFHS GRAD NIGHT MAY 30, 2014
MEDICAL EMERGENCY INFORMATION

Name of Attendee ___________________ Birth Date__________________

Name of Parent/Guardian _______________________________________

Address_________________________________________________         

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 ____________________________________