DISNEY 2017 RANDOLPH MIDDLE SCHOOL
March 8-11, 2017
HEALTH SURVEY AND EMERGENCY INFORMATION
***PARENTS PLEASE COMPLETE THE DOCUMENT AND SIGN WHERE NEEDED***
STUDENT’S LAST NAME FIRST NAME MIDDLE NAME
______
GRADE BIRTHDATE STUDENT ID
______
STUDENT’S HOME ADDRESS ZIP CODE
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HOME PHONE CELL PHONE HOMEROOM TEACHER
______
FATHER/GUARDIAN NAME PLACE OF EMPLOYMENT/PHONE CELL
______
MOTHER/GUARDIAN NAME PLACE OF EMPLOYMENT/PHONE CELL
______
IN CASE OF ILLNESS OR EMERGENCY, THE FOLLOWING PERSONS MAY BE CONTACTED:
OTHER CONTACT NAME PHONE PREFERRED HOSPITAL
______
NAME OF DOCTOR/PHONE NAME OF DENTIST/PHONE
______
In the event my child is involved in an accident or becomes sick to the extent that he/she should not remain at school, I understand that the mother/father/guardian will be notified immediately. If they cannot be contacted, the friend/neighbor listed on this card will be contacted. If the accident or illness is not an emergency, the child will remain at school until arrangements can be made for his/her care.
However, in the event the accident or illness seems so severe that any delay in contacting a parent prior to seeking medical help will be dangerous to the child, or in the event the child needs immediate medical attention and the parents cannot be contacted, the school principal (or responsible person representing the principal in the absence of the principal) has my permission to take the child to a doctor or clinic with the understanding that I will bear the financial responsibility for transportation and treatment.
SIGNATURE OF PARENT/GUARDIAN______DATE_______
Students who have certain physical, emotional, mental, or behavioral conditions may qualify for special services or require special consideration. Please indicate whether any of the following or other conditions exist.
____Allergic Reactions ____Sickle Cell Disease ____Seizures ____Bone/Muscle Problems
____Hearing Loss ____Diabetes ____Asthma ____High Blood Pressure
____Cancer ____Kidney Disease ____Heart Trouble ____Other
Specify Other______
Describe special needs of the student that result from physical, emotional, mental, or behavioral conditions
REGARDING MEDICATIONS AT SCHOOL: It is necessary for us to regard all medications as if they were prescriptions, even Tylenol or aspirin. A medication authorization form, obtained at school, must be completed by the doctor and parent in order for any medication to be given at school.
Medications Taken on Trip
Please list all medications taken on this trip (including any over the counter medications) or indicate no medications being taken.
______
______- No medications are being taken on this trip.
01. Medication Name: ______
Dosage Amount: ______
02. Medication Name: ______
Dosage Amount: ______
03. Medication Name: ______
Dosage Amount: ______
04. Medication Name: ______
Dosage Amount: ______
05. Medication Name: ______
Dosage Amount: ______
06. Medication Name: ______
Dosage Amount: ______