Emergency Medical Information

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! The Samuel School !

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EMERGENCY MEDICAL INFORMATION

Student Name ______________________________________________________ Student age ___________________

Student Birthdate __________________

Allergies or Medications* ______________________________________________ Medical conditions that we should know about_____________________________ __________________________________________________________________ __________________________________________________________________ Dietary Restrictions __________________________________________________ __________________________________________________________________ Parent/Guardian Name(s) ____________________________________________ Home Phone Number_________________Work Phone Number______________ In case of emergency, other than parent, phone number_____________________ Physician’s phone number ____________________________________________

! ! *Our staff is not permitted to dispense medication unless the Request for Over the Counter Medication Administration form or the Physician Statement of Need for Administration of Prescription Medication form has been summited.