Untitled Document

ACADEMY OF THE HOLY FAMILY PERMISSION FOR EMERGENCY CARE

Telephone (860) 822-9272 FAX (860) 822-1318

(To be completed by parent/guardian before the beginning of school year)

Name of Student__________________________________ Grade_____ Social Security #______________________

Address_________________________________________________________________________________________

Street City State Zip Code Country

Student’s Date of Birth: __________________________________ Home Phone #__________________________

Student Lives With: £ Both Parents £Father Only £ Mother Only

£ Father/Stepmother £ Mother/Stepfather £ Grandparents £ Guardian £ Other

Mother’ Name______________________________ Work Phone # _________________________ Hours _____

Mother’s Address_________________________________________________________________________________

(If Different) Street City/State/Zip Code Country

Mother’s E-Mail Address___________________________________ Cell/Pager # _____________________________

Mother’s Workplace & Address____________________________________________________________________

Father’s Name______________________________ Work Phone #_________________________ Hours_________

Father’s Address__________________________________________________________________________________

(If Different) Street City/State/Zip Code Country

Father’s E-Mail Address____________________________________ Cell/Pager #_____________________________

Father’s Workplace & Address_______________________________________________________________________

Name of Person(s) or Agency Having Legal Custody____________________________________________________

Address_________________________________________________________________________________________

Street City/State/Zip Code Country

If Student Lives Between Two Households, Please Designate Emergency Contact:

Name/Relationship___________________________________________ Phone Number(s)_______________________

Parent NOT Authorized to pick up student from school (Must have court papers)

Name_____________________________________________ Relationship___________________________________

Emergency Contact: In the event a parent cannot be reached, you must give the name, address, and phone number of two persons who could pick up and take your daughter home in a timely manner.

1) ______________________________________________________________________________________________

Name Address Relationship Phone #

2) ______________________________________________________________________________________________

Name Address Relationship Phone #

I agree to notify the school within 24 hours if my daughter or any member of my immediate household has developed a communicable disease. I agree to notify the school immediately if the disease if life threatening. I agree to pick up my sick or injured daughter in a timely manner when contacted. The above emergency contacts can be called to pick up my daughter if I cannot be reached. Additionally, in an emergency, if I cannot be contacted, the school has my permission to take my daughter to the emergency room of the nearest hospital and I hereby authorize the medical staff to provide treatment, should a physician deem necessary for the well-being of my daughter.

Signature of Parent/Guardian_______________________________________ Date___________________

Health History Form

Student Name_______________________________________________ Date of Birth__________________________

Personal Physician/Healthcare Provider: Name_________________________________________________________

Address_________________________________________________________________________________________

Street City State/Zip Code Country

E-Mail Address________________________________________ Telephone #_________________________________

Personal Medical History (Please mark yes or no if you have or have had any of the following:

Alcohol/Drug Abuse Yes / No Hearing Problem Yes / No

Anxiety/Depression/Mental Illness Yes / No Hearing Aid(s) Yes / No

Asthma Yes / No Hemophilia Yes / No

Bee Sting or Insect Allergy Yes / No Hepatitis B Disease Yes / No

Cancer Yes / No High Blood Pressure Yes / No

Cardiac Condition Yes / No Measles Yes / No

Chicken Pox Yes / No Mononucleosis Yes / No

Convulsions Yes / No Mumps Yes / No

Dental Problems Yes / No Pollen Yes / No

Diabetes Yes / No Rheumatic Fever Yes / No

Dysmenorrheal (Menstrual Cramps) Yes / No Sickle Cell Anemia Yes / No

Endometriosis Yes / No Thyroid Disorder Yes / No

Epilepsy Yes / No Tuberculosis Yes / No

Gastrointestinal Problems Yes / No Vision Yes / No

Head Injury with Loss of Consciousness Yes / No Special Diet – List Below Yes / No

Other: Explain ____________________________________________________________________________________

_________________________________________________________________________________________________

Please list below (in English) any medication(s) (including dosage), that you take on a regular basis whether at home or at school. This is all confidential information used for Emergency Personnel as necessary.

Acne Epi-Pen

Allergy Headache

Asthma Pain

Anti-Anxiety/Antidepressants Seizure

Birth Control Pills Thyroid

Cardiac

Insulin (Dosage):

Other (Specify):

Allergies: Do you have an allergy or Other Adverse Reactions to any of the following:

If you answer Yes to any, please specify what the allergy is and what to do in case of an emergency.)

Medication Yes / No

List Medication:

Food Yes / No

List Food:

Insect Yes / No

List Insect:

Environmental or Seasonal Yes / No

List:

X-Ray Contrast (Dye that is used) Yes / No

Any Life threatening Medical Yes / No

List:

Consent for Treatment

I grant permission for the Academy of the Holy Family to administer routine medical treatment for my daughter for minor illnesses/injuries and to arrange for any emergency medical care if the circumstances at that time make it impossible for the school to reach me.

Signature of parent/guardian____________________________________ Date_____________________