Emergency Data Update

"*" indicates required fields

Student Information

Please ensure this information is correct so that we can correctly file the student’s emergency data.

Hidden

Student Hash

Parent Name*

Parent Email

Student ID*

Medical Information

Tylenol Permission*

Do you grant permission to administer Tylenol upon the student’s own request?

Yes

Family / Student Physician*

Physician Phone*

Student Medical Details

Emergency Contact Information

Please add up to 5 additional emergency contacts. In the case of an emergency, Jesuit will contact the following persons in addition to parents or guardians, who will be contacted first. Parents / guardians do not need to be added here. NOTE: The emergency contacts listed below will be allowed to sign out a student from school—anyone not on this list WILL NOT be allowed to sign the student out.

Emergency Contacts

First Name	Last Name	Actions

There are no Contacts.

Confirmation*

I understand that I am responsible for the cost incurred for medical treatment for my son’s injuries sustained in activities in which the school has not been negligent. These costs are to be covered by me or my medical insurance plan and be partially covered by the school’s Student Insurance Plan. Should we and the family physician not be available, the school is authorized to send our son to a physician or hospital of its choice.

I agree