STONE HILL
LEARNING CENTER
Academic Excellence. Christian Foundation. Moral Integrity.
HOME
ABOUT US
ADMISSIONS
ACADEMICS
FORMS
NEWS & EVENTS
CONTACT
BLOG
mySHLC
More
Emergency Medical Form
Academic Year 2019 - 2020
Today's Date
Student Information
Insured's Information
Additional Parent/Guardian Contact Information
Additional Emergency Contacts
(at least one required)
Health Insurance Coverage
Additional Information
Does your student carry an epi-pen or any other special medication?
Yes
No
Does teacher in charge have permission to give this medication to the student in the event of an emergency?
Yes
No
Anything else we should know? Learning disabilities, allergies to food or medication, existing medical conditions (including the wearing of eyeglasses or hearing aids), physical limitations, religious limitations, etc.
Signatures
I hereby give permission to the administrators of Stone Hill Learning Center, or the teacher in charge, to arrange for my child to receive medical attention in the event of an emergency. I recognize that every effort will be made to contact me and/or the emergency contact person(s) named above.
Submit