Medical Information

Child's Name *

First

Last

Address *

Phone *

Physician Name

Physician Phone

Does your child have any medical condition we should know about?

Is there evidence of allergies such as eczema, allergic rhinitis, insect stings, etc. which the school should know? (Please specify)

If allergy medication needs to be administered in the event of an emergency, please complete the Medication Permission Form obtained from the school office.

Does the child have any food restrictions? (Please specify)

Signed (Full name of member of DNPCCNS) *

In case my child has an accident or becomes ill and my doctor is not available, I give permission for my child (above) to be treated by the University Medical Center at the Princeton Emergency Room.