Thomas Heyward Academy

Thomas Heyward Academy Student Medical/Emergency Information

Student’s Name: ______Grade & HR Teacher: ______

Date of Birth: ______

In case of emergency, contact the person(s) below in the order listed: Name & Relationship to student Phone# work, home, cell

______

Student Insurance Verification Name of Health Insurer: ______Policy# ______Expiration Date: ______Student’s Physician: ______Phone: ______

EMERGENCY INFORMATION AND MEDICAL TREATMENT CONSENT

I, ______, the parent/guardian of ______, recognize that as a result of participation in student activities, medical treatment on an emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent to in advance to such emergency care, including hospital care, as may be deemed necessary under the then circumstance.

Please provide the following information for your child’s records: Allergies to medications/foods/latex/insect stings/bites/other ______Chronic conditions (indicate medication & condition): ______Relevant medical information (e.g. contact lens, seizures, heart condition, asthma, any previous surgeries): ______

I give the school permission to share this information to protect the health or safety of my child or others.

______Signature Parent/Guardian Date

It is the parent’s responsibility to keep all information current throughout the school year.

I give permission for my child to receive the following medications/treatment as deemed necessary by the School Nurse: 1. Ibuprofen (Motrin) 5. Antibiotic Ointment 2. Benadryl Ointment 6. Orajel 3. Tums Cough drops/throat lozenges 4. Acetaminophen (Tylenol)