New Village: Emergency Contact Medical Info Form 2024-2025

Emergency Contact Medical Info Form 2024-2025
Note: One form for each student please
Student Name*

Last NameFirst Name
Date of Birth*

MonthDayYear
Date
Grade Level*
EMERGENCY & MEDICAL INFORMATION

For use during enrollment at the New Village School. ALLERGY ALERT: (Please list any allergies including medicine, food, bees, etc.)
Any allergies we should be aware of?*

YesNo
Please elaborate
I hereby authorize the staff and any appointed assistants or volunteers of the New Village School to seek emergency medical treatment for my child. In the event of an emergency, I understand and agree that I am financially responsible for any care provided.

I understand that you will take my child to the hospital if deemed necessary.

Name of preferred hospital: name of hospital
In case of emergency or illness, please indicate the order of whom you would like us to contact. We will start with the first person on your list. If we cannot reach the first person, we will continue to the second or third person if necessary. Please note that we will make every attempt to contact in order of your request but we will continue down the list to make sure your child’s needs are immediately met.
Please number 1, 2 or 3 in order of whom you would like us to contact:
Parent 1

Last NameFirst Name
Phone Number
Please enter a valid phone number.
Contact Order
Parent 1 Email*
example@example.com
Parent 2

Last NameFirst Name
Phone Number
Please enter a valid phone number.
Contact Order
Parent 2 Email
example@example.com
Contact the person noted below:

Last NameFirst Name
Relationship with child
Phone Number
Please enter a valid phone number.
Contact Order
Child's Medical Info:
My child may receive (please check):

Rescue RemedyArnicaTylenolAdvil
Child’s Physician:

Last NameFirst Name
Child’s Physician Phone no:
Please enter a valid phone number.
Insurance Info: Company
Insurance Info: ID/Medical Record
Child’s Dentist:

Last NameFirst Name
Phone Number
Please enter a valid phone number.
Insurance Info: Company
Insurance Info: ID/Medical Record
Should be Empty:

Emergency Contact Medical Info Form 2024-2025

EMERGENCY & MEDICAL INFORMATION

Please number 1, 2 or 3 in order of whom you would like us to contact:

Child's Medical Info: