CARES PROGRAM
Health Emergency Information Form

- ADMISSIONS

The maximum number of form submissions has been reached. This form is currently not available.
- PLEASE COMPLETE AND SUBMIT A SEPARATE FORM FOR EACH CHILD.
- CHILD'S NAME:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth: REQUIRED Please fill out this field. Please enter valid data.
- Grade: REQUIRED Please fill out this field. Please enter valid data.
- Room #: Please enter valid data.
- Address Line 1: REQUIRED Please fill out this field. Please enter valid data.
- Address Line 2: Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Home Phone #: Please enter valid data.
- Mother's Cell #: REQUIRED Please fill out this field. Please enter valid data.
- Mother's Work #: Please enter valid data.
- Father's Cell # REQUIRED Please fill out this field. Please enter valid data.
- Father's Work #: Please enter valid data.
- EMERGENCY CONTACTS
  
  In the event of apparent serious illness, accident, or when I cannot be reached, I wish one of the following to be notified by telephone. They may also release and pick up my child/children from the CARES program.
  
  CONTACT #1 (FIRST/LAST NAME) REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  CONTACT #2 (FIRST/LAST NAME) Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  CONTACT #3 (FIRST/LAST NAME) Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
- Please list any special health information such as diabetes, epilepsy, allergies, eye or ear problems, or any other chronic condition: Please enter valid data.
  
  Please list any medications your child is taking: Please enter valid data.
  
  Name of Doctor: REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  PLEASE NOTE: Any medication that must be given during the program must be accompanied by a note from the Doctor, properly labeled and given to the Program Director. If personnel are unable to contact any of the authorized adults listed on this form, the Program Director may make the necessary decisions in any emergency at no expense or liability to Saints Simon and Jude.
  
  Name of medication and instructions on medication administration:
  
  Please check one of the following boxes: I give permission to administer 25 mg Benadryl by mouth if an allergic reaction should occur: I DO NOT give permission to administer 25 mg Benadryl by mouth if an allergic reaction should occur:
- Please let us know if you have any questions or comments:
- THANK YOU FOR SUBMITTING THIS FORM!
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CARES PROGRAM Health Emergency Information Form

CARES PROGRAM
Health Emergency Information Form