*TWO-SIDED*
RETURN BY
August 1, 2012
PLEASE COMPLETE
ONE PER STUDENT
STUDENT’S LAST NAME
STUDENT’S FIRST NAME
2012-2013 Emergency and Medical Information
Part A: Medical Procedures
Whenever possible and prudent, the school will first notify the parent(s) and/or guardian(s) if a student has a
medical emergency. Otherwise, the school will dial 911 for an emergency medical team to transport the
student to a local hospital. The school will make every effort to contact the parents or guardians and give
them specific information. Parents or guardians are responsible for immediately updating the Achieve
website with all contact information changes, as well as updating the school’s main office of any medical
conditions affecting the child. Parents or guardians are responsible for all medical and other costs affiliated
with obtaining medical assistance for their child. https://cook.achieve-technology.us/login.aspx
I hereby certify that I have read this document and I understand its content. Further, I assert that the health
information provided to The Catherine Cook School is current and accurate. I will allow authorization to
share any health information deeded necessary with applicable persons directly involved.
Parent/Guardian Signature
Parent/Guardian Signature
Print Parent/Guardian Name
Print Parent/Guardian Name
Date
Date
Part B: Emergency Contacts
If unable to reach parents/guardians, please list 3 people who you would like the school to contact in case of
an emergency.
Name
Phone
1.
2.
3.
2012-2013 Emergency and Medical Form
Alternative
Phone
Relationship
Out
of State?
□ yes
□ no
□ yes
□ no
□ yes
□ no
Part C: Medical Information
Medical Coverage
Company Name
Policy ID#
Subscriber Name
Group
Physician
Dentist
Physician’s Phone
Dentist’s Phone
Medical Conditions/Medications
Please complete your child’s medical health history for which school personnel need to be aware. Please list
all medications (prescription and non-prescription) administered at home, if any. In addition please note any
medications to which your child is known to be allergic. Finally, please list any medications to be taken at
school for which a Medication Authorization Form is one file. This information allows the school to provide
critical information to emergency medical technicians and care givers.
Health History - Please comment on all that apply.
Allergies:
Hearing Impairment:
High Blood Pressure:
Asthma:
Indigestion:
ADD or ADHD:
Lactose Intolerant:
Chronic Illness:
Learning Disability:
Dietary Restrictions:
Mononucleosis in past 12 Months:
Emotional/Behavioral Disorder/Anxiety:
Nightmares:
Epilepsy/Convulsions/Seizures:
Sinus Problems:
Exercise-Induced Dizziness/Chest Pain:
Skin Sensitivities:
Diabetes:
Vegetarian:
Fainting/Dizziness:
Visual Impairment:
Additional Comments/Other:
Frequent Headaches:
Head/Neck/Back Injuries:
Heart Disease/Defect:
Prescription medications taken at home for treatment:
Medication
1.
2.
3.
Dose
Time