Contact and Medical Information | Al Huda Elementary School

Student & Contact Info

Student Name*

First Middle Last

Student Grade*

Student Section*

Fathers' Name*

First Last

Fathers' Email*

Father's Contact Number*

Mothers' Name*

First Last

Mothers' Email*

Mothers' Contact Number*

Name of Sibling(s)/Grade(s)*

Attending AHES (if no siblings write 'N/A')

Emergency Contact Info

Contacts other than parents

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Number*

Emergency Contact #1 Relation*

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Number*

Emergency Contact #2 Relation*

Medical Info

Does your child have a Medical Condition (ex: allergy, skin condition, health concern, etc)?*

Yes
No

Please specify details about the Medical Condition(s).*

Medication Required at School*

Yes
No

Have you submitted a letter from your doctor stating this medical condition for the new academic year, Sep 2019 -June 2020?*

Yes
No

If your child is on Epipen, please provide the valid Anaphylaxis Emergency Plan -(Click here for the Form) to the office at your earliest but no later than Monday, September 9th, 2019.

Please note that:

It is the parent's responsibility to provide 2 Epipens to school; 1 for the office and 1 for the classroom along with the Anaphylaxis Emergency Plan.
Checking the expiration date on the Epipen is also the parent's responsibility.
Please ensure that the Students name, grade and section are clearly labeled on both the Epipens provided.
It is recommended that students on Epipen wear a MedicAlert wrist band to school at all times.