Microsoft word - emergency sheet '13.doc

Bow High School * Emergency Information *
Parents/ Guardians ~ Please complete and return it to the school nurse.
Remember to notify the school immediately of changes in phone numbers and address and
notify the school nurse of any health changes; medications, health care providers, illness or medical treatment.
Student’s Name: _____________________________________________________________ Grade: ____________ School Year: ______________ D.O.B. _______________ Age: ________ Address: _______________________________________________________ Tel. _________________ Name of Parent/Legal Guardian with whom student lives and relationship:____________________________________________________________ Parent/Guardian Pager/Cell Phone # ____________________ ____________________Parent/Guardian Email: ________________________ Mother’s Employer: ___________________________ Tel._____________ Father’s Employer: _________________________ Tel. ____________ Student’s Physician: ______________________________ Tel. ____________ Student’s Dentist: _______________________ Tel._____________ Student’s Medical Insurance Co: ________________________________Policy # _________________________ Group # ____________________ Friend or relative who would be willing to assume temporary care of your child during school hours if you cannot be reached: Name:____________________________________________________________________________ Tel. __________________________ Please indicate if the student has any of the following:
Has the student been treated for any of the following in the past year?
Is the student on any daily medication(s)? Yes No Medication: __________________ Dose _________ Time taken ______
Last Tetanus Immunization _________________ Type of vaccine ______________
Students needing medication prescription and/or non-prescription during the school day must follow NH laws regarding the
administration of medications in schools. Students may not carry medications except for asthma inhalers and EpiPen (epinephrine)
with proper written approval from a health care provider and parent.
I give permission for the school nurse to administer over the counter medications according to the manufacturer’s instructions to my
child as he/she requests. The following are stocked over the counter medications (their generic equivalent may be substituted):
Tylenol, Advil, Sudafed, Benadryl, Pepcid AC, Pepto-Bismol, Tums, Immodium AD, Eye Saline, Visine, Anbesol, Neo-synephrine,
Isopropyl Alcohol, Hydrogen peroxide, Antibacterial soap, Aloe Gel, Bacitracin, Calamine Lotion, Caladryl, Burn Gel,
Hydrocortisone Lotion, Bee Sting Swabs
No Comments/Exceptions: __________________________________________

In the event of a medical emergency and I can not be reached, this authorization gives consent for the school to call the physician or
dentist listed and to follow his/her instructions or seek emergency medical assistance as needed.
Signature of Parent/Guardian: ___________________________________Date: ________________


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