2021 - 2022
John F . Kennedy Middle School Date
It is essential that we have the following information in order to update our medical records . Please complete and return to your child ’ s school . Please note that some medical information may be shared with your child ’ s teacher ( s ).
STUDENT _________________________ Grade |
Homeroom |
Teacher |
Address Home Phone No . |
|
|
Student lives with : Both parents _____ Mother _____ Father _____ Other |
1 st Parent Name |
Home No . |
Work No . Cell No . |
2 nd Parent Name |
Home No . |
Work No . Cell No . |
Guardian ’ s Name |
Home No . |
Work No . |
Cell No . |
Emergency names and phone numbers to be used when a parent cannot be reached : |
Name Home No . |
Work No . Cell No . |
Name Home No . |
Work No . Cell No . |
Family Physician Preferred Hospital |
Specialist |
Hospital |
Dentist |
Phone No . |
List any serious illness or operation during the past year or during the summer :
For immunizations , please provide documentation with MD signature to the school nurse . List any allergies
Does your child have any of the following :
BEE STING ALLERGY ? FOOD ALLERGY ? ASTHMA ? What medication does he / she take ? What reaction does he / she have ? Is your child receiving allergy shots ?
Does your child have any medical or emotional conditions ? List
Does your child take medication regularly ?
List If your child needs medication at school , please have the proper medical authorization forms filled out by the doctor - secondary students may carry inhalers and Epi-Pens with proper authorization .
Signature of Parent or Guardian ______________________________________
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