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Emergency Information Form

This form is to be completed by the parent/guardian for each student attending MHC Academy. Required fields marked are marked *. This form will be kept on file in the school office and in the nurse's office.

Student's First Name:*

Answer Required

Last Name:*

Answer Required

Grade:*

Answer Required

Attempts are ALWAYS made to contact a parent. In the event a parent cannot be reached, the relatives/friends designated below are authorized to pick up your daughter from school in case of emergency.

Please list only relatives or neighbors who are willing to pick up your daughter in case of illness or accident, or are willing to take responsibility for her in the rare instance of unscheduled early dismissals.

Notify the school immediately if there are any court orders restricting non-custodial parents or others from contact with the child. Provide the Head of School with a copy of the order.

Name/Relationship:*

Answer Required

Best Contact Number (During School Hours):*

Answer Required

Alternate Phone Number:

Answer Required

Name/Relationship:*

Answer Required

Best Contact Number (During School Hours):*

Answer Required

Alternate Phone Number:

Answer Required

Any special conditions, including medications taken regularly, the wearing of contact lenses, etc. (if none, type N/A):*

Answer Required

Any allergies to food, stings, medications, etc. (if none, type N/A):*

Answer Required

Physician's Information

Physician's Name:*

Answer Required

Phone Number:*

Answer Required

Street Address:

Answer Required

City:

Answer Required

Zip/Postal:

Answer Required

Medical Insurance Company:*

Answer Required

Policy/Group No.:*

Answer Required

Dentist's Information

Dentist's Name:*

Answer Required

Phone Number:*

Answer Required

Street Address:

Answer Required

City:

Answer Required

Zip/Postal:

Answer Required

Dental Insurance Company:*

Answer Required

Policy/Group No.:*

Answer Required

I hereby authorize release of medical information to school personnel. In case of medical emergency, I hereby authorize the school to seek emergency medical assistance for our child if we cannot be reached.*

Answer Required

Parent must check here.

Enter Full Name as Signature:*

Answer Required

Date:*

Answer Required

Confirmation Email

Email Required