Trinity Lutheran Emergency Information
Child’s Name: Age: Birth Date:
Address: Home Phone:
E Mail address:

Mother’s Name: Work Phone: Cell Phone:
Father’s Name: Work Phone: Cell Phone:

Care Giver: Phone Number:
Physician’s Name: Phone Number:
Address:

Person to contact if parent’s or caregiver are unavailable:
Name: Phone:
Name: Phone:

I give permission to take my child to the hospital:  Yes No
I give permission for the school to administer first aid to my child:  Yes No
Does your child have asthma?  Yes No
Please list allergies to food or medications:

Signature: Date:

Immunization Record:

VACCINE DOSES M/D/Y BOOSTERS & DATES
Diptheria
Tetnus
Polio
Measles
Mumps
Rubella
HIB
Varicella
Hepatitis A
Hepatitis B
Pneumococcal
PPD

Health Insurance Provider:
Restrictions:
Is your child under treatment?
Operations, accidents?
Physical or emotional problems?