EMERGENCY HEALTH HISTORY

Apollo-Ridge School District

School _____________________ Grade _____ Homeroom Teacher _______________ Bus No. ____________

Student's Name ___________________________________ Birth Date ________________ Locker # ______

    (Secondary)

Address ________________________________________________Phone_________________________

Directions for reaching your home ___________________________________________________________   ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

E-mail Address __________________________________________

Parent/Guardian's _____________________________ _____________________________________

  Names: (Father/Guardian) Last, First     (Mother/Guardian) Last, First

In case of illness ____ Yes, please call parents at work. _____No, please call emergency numbers

Father's Place of Employment __________________________________ Phone # ___________________

Mother's Place of Employment _________________________________   Phone # ___________________

Below is a list of person(s) to contact in case of illness.  Please list in order to be called.  Only persons listed below will be permitted to pick your child up from school when he/she is ill.

  Name   Relationship   Phone

_______________________________ __________________________ ______________________

_______________________________ __________________________ ______________________

_______________________________ __________________________ ______________________

_______________________________ __________________________ ______________________

PLEASE PROVIDE THE FOLLOWING MEDICAL INFORMATION

  _______________________________________ ________________________________________

  Physician   Phone

_________________________ __________________________ 

  Dentist       Phone

  HOSPITAL PREFERRED IN THE EVENT OF AN EMERGENCY _______________________________

  Health Problems or Allergies (including bee stings)________________________________________

  ___________________________________________________________________________

  Prescribed Medications ___________________________________________________________

  Immunizations received during the summer ___________________ ___________________

Date Date

  The above medical information will be shared with the appropriate school personnel as needed.

The school physician or dentist has my permission to do the required examinations if the appropriate forms have not been completed by my private physician or dentist and returned to school.

Date ______________    ________________________________________________________

Signature of Parent/Guardian

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