Nampa Christian Schools

NCS Emergency/Medical Information Form 2012/2013

NCS Yearly Student Emergency/Medical Information Form 2012/2013

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Student 1 Information

Student 1 Name *


First Name	Last Name

Student 1 Grade *

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Student 1 Gender *

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Student 1 Date of Birth *

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Does Student 1 Participate in Athletics?

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Student 1 Allergies (please write N/A if none) *

Student 1 Allergies to Medication (please write N/A if none) *

Student 1 Medical Condition (please write N/A if none) *

Because NCS cannot give any medication to students without proper authorization from their parent, and only within the guidelines of the Medication Administration Policy, we give permission for our child to receive Acetaminophen (Tylenol or Ibuprophen at the discretion of the NCS Nurse or appropriate school personnel.

Student 1 permission to take Acetaminophen (Tylenol) *

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Student 1 permission to take Ibuprophen (Advil)

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Student 2 Information

Student 2 Name


First Name	Last Name

Student 2 Grade

Select from list

Student 2 Gender

Select from list

Student 2 Date of Birth

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Does Student 2 Participate in Athletics

Select from list

Student 2 Allergies (please write N/A if none)

Student 2 Allergies to Medication (please write N/A if none)

Student 2 Medical Condition (please write N/A if none)

Student 2 permission to take Acetaminophen (Tylenol)

Select from list

Student 2 permission to take Ibuprophen (Advil)

Select from list

Student 3 Information

Student 3 Name


First Name	Last Name

Student 3 Grade

Select from list

Student 3 Gender

Select from list

Student 3 Date of Birth

Click in box to select date

Does Student 3 Participate in Athletics?

Select from list

Student 3 Allergies (please write N/A if none)

Student 3 Allergies to Medication (please write N/A if none)

Student 3 Medical Condition (please write N/A if none)

Student 3 permission to take Acetaminophen (Tylenol)

Select from list

Student 3 permission to take Ibuprophen (Advil)

Select from list

Student 4 Information

Student 4 Name


First Name	Last Name

Student 4 Grade

Select from list

Student 4 Gender

Select from list

Student 4 Date of Birth

Click in box to select date

Does Student 4 Participate in Athletics?

Select from list

Student 4 Allergies (please write N/A if none)

Student 4 Allergies to Medication (please write N/A if none)

Student 4 Medical Condition (please write N/A if none

Student 4 permission to take Acetaminophen (Tylenol)

Select from list

Student 4 permission to take Ibuprophen (Advil)

Select from list

Parent Information

Father's Name


First Name	Last Name

Father's Address *


Address

Address Line 2

City	State	Zip Code

Father's Home Phone Number *

Phone Number

Father's Work Phone Number *

Phone Number

Father's Cell Phone Number *

Phone Number

Father's Employer's Address *


Address

Address Line 2

City	State	Zip Code

Father's E-Mail Address *

Email Address

Mother's Name *


First Name	Last Name

Mother's Address *


Address

Address Line 2

City	State	Zip Code

Mother's Work Phone Number *

Phone Number

Mother's Cell Phone Number *

Phone Number

Mother's Employer's Address *


Address

Address Line 2

City	State	Zip Code

Mother's E-Mail Address *

Email Address

Student Lives With: *

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Emergency Contact Name 1 *


First Name	Last Name

Contact Relationship 1 *

Select from list

Contact 1 Home Phone Number *

Phone Number

Contact 1 Cell Phone Number *

Phone Number

Emergency Contact Name 2 *


First Name	Last Name

Contact Relationship 2 *

Select from list

Contact 2 Home Phone Number *

Phone Number

Contact 2 Cell Phone Number *

Phone Number

Physician/Dentisit/Insurance Information

Physician's Name


First Name	Last Name

Physician'a Phone Number

Phone Number

Physician's Address


Address

Address Line 2

City	State	Zip Code

Dentist's Name


First Name	Last Name

Dentist's Phone Number

Phone Number

Dentist's Address


Address

Address Line 2

City	State	Zip Code

Insurance Company Name

Policyholder's Name/Policy Number

In the event our child/children become(s) ill or sustains injury while in the care of Nampa Christian Schools and the school is unable to reach us, we give our permission to those in charge to take whatever steps are necessary. If it is not possible to reach the physician named, consent is given to any licensed physician or dentist to perform such emergency procedures as they think the existing emergency requires. Please communicate with the School Nurse any health issues that may be a cause for concern at school.

Signature (authorizing treatment) *

Date *

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* required