Health Form and Emergency Contacts Form Serious Health Conditions Please complete this form and sign at the bottom. This information will help school staff provide a safe learning environment for your child. It is the responsibility of the parent to inform the school if your child’s emergency contact information or health condition changes during the school year. If your child needs assistance or supervision to take medication at school, an authorization form must be completed and signed by your physician. This form is available from the school office. Name of Student: Grade: Personal Health Number (CareCard): EMERGENCY CONTACT #1 (not including parents) Name: Relationship: Home Phone: Cell Phone: Authorized Pickup YesNo EMERGENCY CONTACT #2 (not including parents) Name: Relationship: Home Phone: Cell Phone: Authorized Pickup YesNo HEALTH QUESTIONS 1. Does your child have any of the following medical conditions which may require emergency care at school? Severe AsthmaSeizure Disorder / EpilepsyLife-Threatening Allergy (Anaphylasix) - please state details in question 2 belowDiabetesOther - please state details in question 2 belowNone of the Above - ignore questions 3 and 4 2. If you selected "Life-Threatening Allergy (Anaphylasix)", please note what the allergy is to. If you selected "Other", please note the medical condition. 3. Is there anything the school staff needs to know about these conditions? 4. In the event of a medical emergency at school, what action is necessary for the above conditions? ELECTRONIC SIGNATURE Please sign this form by entering your full name and the date. Your typed name and date will together serve as your signature for this Legal Residency form and treated by John Knox Christian School as a physical handwritten signature on a paper form. Full Name of Student: Full Name of Parent: Date: (yyyy-mm-dd) Parent's Email Address: The information on this form is collected under the authority of the School Act, Sections 13 and 97. The information will be used for the student’s educational program and administrative purposes and, when required, may be provided to health services, social services or other support services as outlined in Section 97(2) of the School Act. The information will be protected under the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of this information, please contact your school principal.