Upward Bound - (AY) Medical Emergency Form

Student Name Student Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
School
Grade
Gender

Gender Male Female Non-binary Other Other
Cell Phone Cell Phone - ### - ### ####
Last Four Digits of Social Security Number
Primary Emergency Contact Name Primary Emergency Contact Name First Last
Primary Emergency Contact Phone Primary Emergency Contact Phone - ### - ### ####
Secondary Emergency Contact Name Secondary Emergency Contact Name First Last
Secondary Emergency Contact Phone Secondary Emergency Contact Phone - ### - ### ####
Does your student have any allergies that emergency personnel should be aware of when treating your student?

Does your student have any allergies that emergency personnel should be aware of when treating your student? Yes No
If so, please list those allergies.
Does your student have any medical conditions that emergency personnel should be aware of when treating your student?

Does your student have any medical conditions that emergency personnel should be aware of when treating your student? Yes No
If so, please list those medical condition(s.)
Please list any medication(s) your child is currently taking, the dosage amount, and the reason for taking it, if any.
Family Health Insurance Information:
Carrier:
Group Number:
Policy #:
Carrier Address:
Insured Person’s Name:
Relationship to Insured:
I.D. #:
Signature

I release the above information to Upward Bound only to be used in case of an emergency.

I understand all above information will remain confidential.
Signature of Parent/Guardian (or student, if over age 18)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Upward Bound - (AY) Medical Emergency Form

Upward Bound - (AY) Medical Emergency Form

Family Health Insurance Information:

Signature