Date:_____________

Student’s Name:

Birth Date:__________________ Age:____________ Sex:

Parent’s Name:

Home Address:

Home Phone:____________________ Business Phone:

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name

Relationship:__________________________ Phone

Family Doctor _________________ Phone number

Family Health Plan Carrier

Policy Number

Signature:___________________________________ Date:

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications, will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.

Signature:__________________________________ Date:

I grant permission for non-prescription medications (such as aspirin, throat lozenges, cough syrup, etc.) to be given to my child, if appropriate.

Signature:__________________________________ Date:

Specific Medical Information: (The parish will take reasonable care to see that the following information will be held in confidence.)

Allergic Reactions: (medications, foods, plants, insects, etc.)

Immunizations: Date of last tetanus/diphtheria

Is student subject to chronic homesickness, emotional reactions, sleepwalking, fainting?

Medically prescribed diet?

Any physical limitations?

My child has the following special medical conditions: