Paris Strings

Medical Information

➨ PLEASE SEND YOUR CHILD’S HEALTH INSURANCE CARD (or a copy).  We will copy the card and return it to you.  If your child does not have medical insurance, please check the box below.  You will be responsible for hospital/doctor fees incurred by your child.

q   My child does not have health insurance.

✴ EMERGENCY PROCEDURES should be listed on the attached page. Please indicate what procedures you want us to follow if your child gets hurt, or becomes ill.  Please list phone numbers of those you want contacted.

✴         Student:                 Age

Address:

                Birthdate

Parent(s) / Guardian:

Phone:   home -                 work -

Cell -

✴ Health History Allergies Permission granted for the following    Asthma                                                Aspirin medications to be administered:

  Cardiac Problems                             Penicillin                            q    Aspirin

  Diabetes                                              Sulfa                                    q    Tylenol

  Orthopedic Problems                     Insect Bites                       q    Other

  Other  (specify)                               Other (Specify)              

All medication must be personally handed to your child’s chaperone.  It must be marked with your child’s name and accompanied by specific, handwritten instructions.

✴ My child has received a tetanus shot within the past 6 years.     Date:

✴ q    My child has no known health problems that should require a limited program of physical activity or participation.  If so, please explain IN DETAIL on the reverse side of this form.

Emergency Information

Student Name:

Provide specific instructions for emergency care:

Emergency Contacts & Phone Numbers:

Phone #

Phone #

Phone #