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MEDICAL ALERT FORM

Child’s Name: ________________ D.O.B: ____________________

Medical Alert Condition (as stated on school records):


_______________________________________________

Agencies/people to contact in case of an emergency:

__________________________________ Phone No.: ____________

__________________________________ Phone No.: ____________

__________________________________ Phone No.: ____________

The following steps outline the action I would like the school to follow in the
event of an emergency with my child:
1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

5. ___________________________________________________________________

My child is currently on ________________________________________________

(Please elaborate on the type of medication and any side effects)


___________________________________________________________________________

Please state any medication that causes an allergic reaction in your child: e.g.
penicillin
_____________________________________________________________________
_____________________________________________________________________

I give permission for this medical information, including a picture, on my child


to be displayed on the staff notice board. (If required)

Yes

No

____________________ ____________
Parent Signature Date

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