medical - Trinity Christian Academy

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Date Submitted

Name(Required)

First Last

Grade(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Medical information

Please check and/or list any medical conditions your child has:

Asthma

Diabetes Type I

Diabetes Type II

Heart Condition

Bleeding Disorder

Epilepsy

Sickle Cell

Other

Other medical conditions:(Required)

Are there any limitations on school activities?(Required)

Yes

Please explain:(Required)

Does the student take any medications on a regular basis that may be required at school activities?(Required)

If yes, a TCA MEDICAL AUTHORIZATION FORM must be completed.

Yes

Does the student require any emergency medication such as an Epi-Pen or a rescue inhaler?(Required)

Yes

Please explain:(Required)

Allergies

Does the student have any alleregies? (ex: food, insects, medication, etc...)(Required)

Yes

Allergies(Required)

Name/Type

Severity (mild, moderate or severe)

Does the student require an Epi-pen?(Required)

Yes

Signs/Symptoms of allergic reaction:(Required)

Emergency Care Plan

If you answered yes to any of the previous questions complete the rest of this form.

Medical Condition(s) Requiring Emergency Care Plan:(Required)

Possible Emergency Situations(Required)

Scenarios(Required)

If this occurs:

Do this:

Emergency Information

Mother's Cell(Required)

Mother's Work

Father's Cell(Required)

Father's Work

Emergency Contact Name(Required)

Relationship to Student(Required)

Emergency Contact Cell(Required)

Emergency Contact Work

Preferred Hospital

Authorization for Emergency Medical Care

Consent(Required)

I understand that it is my responsibility to notify the school medical professional immediately and update any necessary paperwork if any changes are made to medications and/or doctor’s orders for the above stated child. In case of an emergency, I authorize any representative of Trinity Christian Academy to refer to this emergency care plan in regards to treatment of the above stated child. I also authorize any representative of the Trinity Chirstian Academy to act on the above stated child’s behalf and seek emergency medical care as needed.(Required)

Parent/Guardian Signature(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Trinity Forms

Student Medical Alert & Emergency Care Plan

Medical information

Allergies

Emergency Care Plan

Emergency Information

Authorization for Emergency Medical Care

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