Eagle's landing christian academy

THE EARLY LEARNING ACADEMY Teacher_______________________
Medical Information and Release Form for the School-Year 2010-2011 _______________________________________________________________________
Last Name
"Goes By"

____________________________________________________________________________________________( ) Regular ( ) Often ( ) Occasional
Family E-mail Address
Name of Family Church Church Attendance

____________________________________________________________________________________________________________________________
Home Address
Home Phone

Student lives with: _____ Both Parents _____ Mother _____ Father _____ Other (_______________________________________)
___________________________________________________________________________________________________________________________
Father's Name
Occupation/Title/Place of Employment Work Phone

___________________________________________________________________________________________________________________________
Mother's Name
Occupation/Title/Place of Employment Work Phone

The clinic personnel have my permission to give the following: (A note will be sent home if meds are given.)
Tylenol Y___N___

A child must wait 24 hours before returning to school if his/her temperature is 100.0 or higher.
What daily medication is the student taking? _______________________________________________
To what food/medication is the student allergic? ______________________________________________
Any other allergies?______________________________________________________________________
Please have MD fill out allergy action plan form and return to school. Must bring in epipen.
Does the student have asthma? __ Yes* __ No (*Please be sure we have an extra inhaler at school at all times.)
Explain any other important medical fact we need to know. ___________________________________________
In the event of an allergic reaction or insect sting, the school may give Benadryl or apply Benadryl Cream: __ Yes __ No

In the event my child is sick or injured and I cannot be reached, please contact the following person(s) (in this order.) My child may also be released to
the
following person(s):
1.
______________________________________________________________________________________________________________________
Relation to Child
Day Phone/Cell
______________________________________________________________________________________________________________________
Relation to Child
Day Phone/Cell
______________________________________________________________________________________________________________________
Relation to Child
Day Phone/Cell
___________________________________________________________________________________________________________________________

Child's Physician
Hospital choice

Note: All medication must be sent to the school by the parent or guardian. Parents or guardians may send medicine for a child
if both proper instructions and original containers are sent with the medicine. If your child is prone to have headaches,
please send medication at the beginning of the school year to be available as your child needs it.
Sometimes, but not often, accidents happen and children are injured while at school or on a school function. ELCA employs a nurse
to provide assistance with accidents that result in injuries. However, ELFBC, ELCA, and their staff of employees are not responsible
or liable for damages or the costs of further medical care or treatment that the injury may necessitate.

In the event of an accident or illness and neither parent nor legal guardian can be contacted, the school administrators and/or
their assignees have my permission to take whatever emergency measures that they deem necessary, including but not limited
to: admission to a hospital, clinic or any other medical facility. Also, in the event that emergency surgery would need to be
performed, on behalf of my child and/or ward, I give my permission for this or any other treatment necessary.
If there is an emergency and the facility has to be evacuated, my child has my permission to ride school transportation.
______________________________________________________________________________
Signature of Parent or Legal Guardian Date

Source: http://www.elcaonline.org/clientimages/28102/tankersleyt/forms/ela%20medical%20form.pdf