Grade_________ Homeroom_________ Birth Date__________	Lebanon Catholic School Emergency Card	2007-2008

Name of Student ____________________________	Lives With __________________________________
Address __________________________________	Phone ________________ Cell Phone_____________

Address Change __________________________________________
Father _________________________________________________	Daytime Phone ___________________________________
Work/Daytime Location ___________________________________	Workphone ______________________________________
Mother ________________________________________________	Daytime Phone ___________________________________
Work/Daytime Location ___________________________________	Workphone ______________________________________

Please, in whom would you like called first: ______________________________________________________

Name of Relative or Neighbor we can call in case you are not home.
Name: _____________________________________	Relationship: _______________________________________
	Phone Number: _____________________________________
Name: _____________________________________	Relationship: _______________________________________
	Phone Number: _____________________________________

Medication Policy

PLEASE REFER TO STUDENT/PARENT HANDBOOK

FOR MEDICATION & OTHER HEALTH

SERVICE POLICIES AND PROCEDURES.

I give my consent for the School Nurse to administer with

Discretion to the above named student, following Medication when needed:

Acetaminophen (Tylenol or Yes No

Approved aspirin substitute)

Parent Signature_________________________________________

Emergency Authorization

In the event that my child and/or would become ill or is injured

While attending or traveling to or from any school event any
school of the Lebanon Catholic School or any school function. I, as parent and /or guardian, hereby authorize the Lebanon Catholic School or any of its representative to transport my child to a hospital or Physician if neither parent can be contacted

after reasonable investigation and if the Lebanon Catholic School feels that immediate medical evaluation is necessary.

I further authorize the physician or hospital to whom my child is taken to

render any necessary medical or surgical treatment which is deemed necessary

under the circumstances.

Parent Signature_________________________________________

Family Physician________________________________________

Telephone_________________________________________

Health Information

The following information could be vital in the event

of an emergency. This information may be shared with

School staff for the safety and educational welfare of

your child.

Please List:

All Medical Conditions:

__________________________________________

All prescriptive Medication/Inhalers (at home and/or

School) (Include name, dose, & time of Medication)

__________________________________________

Allergies:

____________________________________