IICA

FORM 3

Rev. 1/10/02

 

Souhegan High School

Student Health Information Sheet

 

Instructions: This form will provide to the doctor or medical personnel to which your child is taken in the event of a medical emergency while on a school-sponsored or school-endorsed field trip. Please complete ALL sections as accurately as possible.

 

Student’s Name:_______________________________________________

 

Home Address: _______________________________________________

 

Telephone Number:________________  Date of Birth: ________________

 

Emergency Contacts:

 

Mother: _____________________________  Telephone: _____________________

 

Father: _____________________________   Telephone: _____________________

 

Other Contact: ________________________ Telephone: _____________________

 

Family Doctor: ________________________Telephone: _____________________

 

General Information:

 

  1. Food or drug allergies: __________________________________

 

  1. Other Allergies: _______________________________________

 

  1. Date of last tetanus shot: ________________________________

 

  1. Present medications: ____________________________________

 

  1. Chronic medical problems: _______________________________

 

  1. Other items of concern: __________________________________

 

Parental Authorization

 

In case of medical emergency, in the event I cannot be reached, I authorize Souhegan High School, its agents, employees and other officers to procure and consent to any medical examination, diagnostic process or course of treatment, including hospital care, to be rendered to my child by or under the supervision of any duly licensed doctor, dentist, surgeon, or other health care professional.

 

__________________________                                _________________________

Date                                                                             Parent or Guardian

 

__________________________                                _________________________

Health Insurance Company                                          Policy