Date Format: MM slash DD slash YYYY
When child is ill or injured, please list which parent/guardian the school should notify first. Please list in preferred order of contact.
In case parent can’t be reached, please contact the individual below: This person has agreed to assume this responsibility and is local.
Mark the box if your child has a history of the following conditions. Mark additional information as needed. Additional forms may need to be completed by your physician (marked with *). Forms available on school website.
Doctor’s note required for explanation*
List medication towards the end of the form
List ALL medications taken regularly at home or at school. Please specify frequency and reason for use.