Home School Program | Stone Hill Learning Center

Emergency Medical Form

Academic Year 2020-2021

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

Does teacher in charge have permission to give this medication to the student in the event of an emergency?

Yes

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.

STONE HILL LEARNING CENTER

Academic Excellence. Christian Foundation. Moral Integrity.