Emergency Medical Form

School Year: *

List all applicable students in your family.

Student 1

Last *

First *

Middle

Grade *

Date of Birth *

Student 2

Last

First

Middle

Grade

Date of Birth

Student 3

Last

First

Middle

Grade

Date of Birth

Student 4

Last

First

Middle

Grade

Date of Birth

Home Address *

Parents' / Guardians' Names *

Home Phone *

Father's Work

Father's Cell

Family Doctor *

Health Insurance Provider *

List any allergies that your child has:

List any medical conditions of which your child should be aware:

List medications that your student takes on a regular basis:

Is your child under the care of a doctor? If so, for what reason?

Remarks:

Emergency Contact 1

Name *

Home Phone *

Work Phone

Cell Phone

Address

Emergency Contact 2

Name *

Home Phone *

Work Phone

Cell Phone

Address

School Emergency Procedures

In case of emergency and/or need of IMMEDIATE medical or hospital care:

1. The school will call 911 for obvious injuries/medical conditions requiring immediate medical care. (If transported to the hospital, the student will be escorted by an HCA staff member unless otherwise agreed upon by the parents/staff.)

2. The school will attempt to contact the parents/guardians until they are reached.

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Contact Us

1101 Delaware Street New Castle, DE 19720

302-654-2613

info@hcade.org