Clear Creek Church - Preschool Medical

Student's Name

Father's First and Last Name

Cell Number

Mother's First and Last Name

Cell Number

Full Address

If parent(s) cannot be reached, and child needs to go home, who else may we call? Please list in order of preference. They must be able to pick up the child if necessary.

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Family Doctor

Phone

Family Dentist

Phone

Does this child have alergies?
Yes
No

If yes, please specify

Is an Epi-pen required/prescribed by a doctor?
Yes
No

Does your child carry and Epi-pen with him/her?
Yes
No

If yes, Doctor's Order (school form) is required. Parent is responsible for providing the Epi-pen.

Does this child have asthma?
Yes
No

If yes, list triggers and symptoms:

Has your doctor prescribed an inhaler?
Yes
No

If yes, list name of inhaler.

If yes, Doctor's Order (school form) is required. Parent is responsible for providing the inhaler.

Does this child have any chronic medical illnesses or conditions?
Seizures
Diabetes Type 1
Type 2
Cardiac Condition
Other

If Other (please specify)

Please list any other important information that will help us better care for your child while at school.

Please list any medications and reason for taking them at home.

All prescription medications that need to be given during school hours must have a Doctor's Order (school form) and be kept in the school office.

This confidential information is shared with staff for the sole purpose of protecting the health and well-being of the student. By signing below, you allow the school to share any information deemed appropriate. If a parent cannot be notified, and emergency care is necessary, I hereby give permission for this student to be transported to the nearest hospital and I give permission for the hospital to give emergency treatment as may be needed. I will assume full responsibility for fees incurred by such an emergency.

Parent's / Guardian's Signature (typing my name constitutes my signature and consent)

Date

Preschool Medical Release Form

Medical Release Form for Clear Creek Preschool