Graves County Home Education Co-op Graves County Home Education Co-op Graves County Home Education Co-op
 

Medical Form

indicates a required answer

MEDICAL FORM

Parents are present with their children at most GCHE Cooperative activities. Occasionally, however, a parent cannot attend an activity and may allow their children to attend under the supervision of another parent. Since it is important to avoid accidents or predict when they might occur, the following information is requested so that the co-op may seek emergency medical treatment if a student is injured and the parent is not present. We will make every effort to contact the parents before obtaining medical help if time permits.

1. *

NAME OF FAMILY
2. *

ADDRESS
3. *

FATHER'S NAME
4. *

FATHER'S CELL
5. *

MOTHER'S NAME
6. *

MOTHER'S CELL
7. *

EMAIL ADDRESS
8. *

EMERGENCY CONTACT
9. *

PHONE NUMBER
10. 

NAME OF PRIMARY PHYSICIAN
11. 

PHONE NUMBER
12. 

INSURANCE COMPANY
13. 

POLICY #
14. *

CHILD NAME
15. *

DATE OF BIRTH
16. *

ALLERGIES
17. *

MEDICATIONS
18. *

ANY LIMITATIONS
19. 

CHILD NAME
20. 

DATE OF BIRTH
21. 

ALLERGIES
22. 

MEDICATIONS
23. 

ANY LIMITATIONS
24. 

CHILD NAME
25. 

DATE OF BIRTH
26. 

ALLERGIES
27. 

MEDICATIONS
28. 

ANY LIMITATIONS
29. 

CHILD NAME
30. 

DATE OF BIRTH
31. 

ALLERGIES
32. 

MEDICATIONS
33. 

ANY LIMITATIONS
34. 

CHILD NAME
35. 

DATE OF BIRTH
36. 

ALLERGIES
37. 

MEDICATIONS
38. 

ANY LIMITATIONS
39. 

CHILD NAME
40. 

DATE OF BIRTH
41. 

ALLERGIES
42. 

MEDICATIONS
43. 

ANY LIMITATIONS
44. 

CHILD NAME
45. 

DATE OF BIRTH
46. 

ALLERGIES
47. 

MEDICATIONS
48. 

ANY LIMITATIONS