Concord Carlisle High School Student: ____________________________ Student ID#__________________

Health Office Information Card

Date of Birth: _______________________ Grade______________ Teacher/HR: _________________________

Address: _________________________________________ Legal Guardian______________________________

Living Arrangement: (__) Mother (__) Father (__) Both (__) Other________________________

Health Insurance______________________________________ No insurance at present time

If medical emergency arises, we want to respond according to your wishes. Please provide the following information and indicate the order in which people should be contacted.

(__) Father’s Name: ___________________________________________ Cell#/Car#:___________________

Home Address: ___________________________________________ Home Tel#:___________________

Work Name: ___________________________ City: ______________ Work Tel#:___________________

(__) Mother’s Name: ___________________________________________ Cell#/Car#:___________________

Home Address: ___________________________________________ Home Tel#:___________________

Work Name: ___________________________ City: ______________ Work Tel#:___________________

Please list 2 neighbors and/or relatives whom we may call, or to whom we may release your child in an emergency.

(__) Name: ________________________________ Address:_________________ Tel#:____________________

(__) Name: ________________________________ Address:_________________ Tel#:____________________

Doctor:_____________________ Tel#:______________ Dentist:_____________________ Tel#:______________

I authorize the school nurse or her delegate to administer Tyelenol (Acetominophen) to my child according to school medication protocol.

(__) Yes (__) No Parent/Guardian Signature: __________________________ Date:__________________

Allergy	Describe Reaction	Describe Treatment
Food:
Medications:
Other:
Asthma: (__) Yes (__) No

OFFICIAL USE ONLY – PRN Medication

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