Contact And Medical Info

Contact and Medical Info 2024-2025

"*" indicates required fields

Student & Contact Info

Student Name*

First Middle Last

Student Grade & Section*

Fathers' Name*

First Last

Mothers' Name*

First Last

Fathers' Email*

Mothers' Email*

Father's Contact Number*

Mothers' Contact Number*

Home Phone Number

Address

Please fill if you haven't already updated our record.

Street Address Address Line 2 City Province Postal Code

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

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

Medication Required at School*

Yes

If your child is on Epipen, please provide the valid Anaphylaxis Emergency Plan -(Click here for the Form) to the office at your earliest..

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.