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Emergency Contact/Medical Information

Student Information

Grade
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Parent / Guardian Information (Primary Contact)

Live with student?
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Parent / Guardian 2

Lives with Student?
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Emergency Contacts: Should an emergency occur (e.g., sickness, transportation, school closing) and a parent/guardian cannot be reached, we will notify a responsible adult, relative, friend or neighbor. Valid identification may be requested.

Emergency Contact 1

Emergency Contact 2

Please complete the sections below:

Is Student on an IEP?
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Is Student on Medication?
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At Home?
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At School?
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Does Student have allergies/other health concerns?
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Hull Public Schools has Standing Orders from our School Physician Consultant, Dr. Martin Iser, for limited over-the-counter medications. I give permission for my child to be given the following medications per standing order guidelines. (Check all that apply)

Check all that apply
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Custody Restrictions?
Answer required for "Custody Restrictions? "

Safe to School Program: Please call the school before 9:00 am on the day your child will not be in school. If we do not receive a call, we will try to reach a parent or guardian at the Priority Phone Number listed on this form.

In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, the school may make whatever arrangements that seem necessary.

Parent/Guardian Signature and Date*
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