Coatesville area school district ~ emergency information

_____________________________________________________\_____\_____\_________________________________________ Last Name __________________________________________________________________________________________________________ Home Address Resides with: Mother ____ Father ____ Both ____ Guardian ____ Guardian’s Name: ____________________________________ Mother’s Name ________________________________________ Father’s Name ________________________________________ Place of Employment ___________________________________ Place of Employment ___________________________________ Work # ___________________ Home # _____________________ Work # _____________________ Home # __________________ Cell # __________________ Email ________________________________________________ Email ________________________________________________
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________ Name MEDICAL HISTORY
Is your child allergic to bee/insect stings? No/ Yes Reaction and treatment: ______________________________________________
Is your child allergic to anything else? No/Yes What and treatment: ________________________________________________
Is your child taking any medication at home or school? No/Yes What/Why: ______________________________________________
Please list any history of medical conditions/concerns (asthma, diabetes, epilepsy, cardiac, ADD, etc.): _________________________
Doctor ______________________ Phone ____________________ Dentist ____________________ Phone ____________________
Does your child wear glasses? _____ Contact Lenses? ______ Hearing aides? _____ Other/Name _____________________________
Name/School of siblings attending Coatesville Area _________________________________________________________________
Insurance Company ___________________________________________________ Policy Number __________________________
I give my permission for my child to receive the following medications provided by the CASD and dispensed by the school nurse of
the principal’s designee:
Acetominophen (Generic Tylenol)
Essence of Peppermint (for stomach aches) MEDICATION POLICY: If any medication must be sent to school, it must be in its original container accompanied by a signed note or school consent form from the parent or legal guardian. All medication must be dispensed in the Health Room according to the package directions or doctor’s note. This applies to both prescription and over the counter medications. If any medication sent to school is not in its original container, it will not be dispensed. Authorization for Emergency Services Treatment of Minor
I hereby give my permission for my child (name) _________________________________________________ to be treated at Brandywine Hospital for any emergencies. I also give my permission for the information on this card to be shared with appropriate school personnel. I hereby authorized the Coatesville Area School District to release to and obtain information from the family health care provider (immunizations, diagnoses, treatments). ___________________________________________ __________________


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