Emergency Medical Form
Academic Year 2021-2022

Student Information

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

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.