Health and Emergency Information Form
Please fill out this form and click submit.
Students Name (List All)
*
Parent's email
*
This address will receive a confirmation email
Allergies
Please list any allergies your child may have, as well as severity of the allergy. If an Epi-pen is needed, please include that information below. If none please enter N/A.
*
Special Physical, Mental, or Emotional Needs:
Does your child have any of the following?
*
Please select all that apply.
ADD
ADHD
Asthma
Epilepsy
Autism
Down syndrome
Other (if other please explain below)
Not Applicable
Other (please list other needs here):
Does your child take medication?
*
Please select all that apply.
Yes
No
Not Applicable
If Yes, will your child be taking it during RLC hours (1-4:30PM Thursdays / 9am-3pm Fridays)
*
Please select all that apply.
Yes
No
Not Applicable
If YES, include specific information for giving the medication.
Emergency Contact Information:
In case of emergency, please provide the names and phone numbers of 2 emergency contacts:
Emergency Contact #1 NAME:
*
Relationship to Student:
*
Phone Number:
*
Emergency Contact #2 NAME:
*
Relationship to Student:
*
Phone Number:
*
Submit
Description
Please fill out this form and click submit.
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