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Emergency Information for Teacher's File
2016-2017
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* Indicates required question
Student's full name and Grade Level
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Your answer
Date of birth (mm/dd/yyyy) /Present age
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Your answer
Emergency Contact (enter name(s) and phone numbers)
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Your answer
Medical history: List any pertinent details current or past (or respond "none")
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Your answer
List any known allergies (or respond "none")
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Your answer
If your child is on medication, give name of medication and dosage (or respond "none")
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Your answer
Primary care doctor/ Doctor's office phone number
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Your answer
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