Student Emergency Information

First name

Middle name

Last name

Birthdate

Address

Home Phone Number

Cell Phone Number

Graduation Year

INSURANCE INFORMATION:

Insurance Company

Group Number

Identification/Med Record #

Policyholder's Name (name policy is under)

Insurance Co. Emergency/Information Phone #

Is there a specific St. Paul area hospital/urgent care center to which your insurance company wants you to be taken in the event of an emergency? (Please contact your insurance provider for this information if you are unsure.)

Name of Hospital/Urgent Care Center

(Unless otherwise specified, paramedics and/or staff will determine hospital to which student will be transported.)

EMERGENCY HEALTH INFORMATION:

Please list any medications (i.e. prescription drugs, aspirin, vitamins, etc.), allergies, chronic health problems (i.e. asthma, seizures, etc.) – anything which might affect procedures or treatment in an emergency situation.

EMERGENCY NOTIFICATION:

I want the following persons (parent, guardian, relative, family friend) notified in the event of a health emergency: