Parent Medical Form

Please complete this form for each child attending Trinity Preschool of Berwyn this year. If you have more than one child attending Trinity Preschool, please submit this form separately for each child. For the 2021-2022 school year, forms must be submitted by August 9th, 2021.

"*" indicates required fields

Student Information

Student's Name*

First Last

Student's Address*

Street Address Address Line 2 City State ZIP Code

Home Phone Number*

Student's Birthdate*

Parent & Emergency Contacts

Parent Emergency Contact #1*

First Last

Parent #1 Cell Phone*

Parent #1 Email Address

Parent Emergency Contact #2*

First Last

Parent #2 Cell Phone*

Parent #2 Email Address

Non-Parent Emergency Contacts: In case of emergency, these contacts may have access to my child's health information. These contacts will be who your child is released to when a parent or guardian cannot be reached.

Emergency Contact #1*

First Last

Daytime Phone*

Cell Phone*

Emergency Contact #1 Address*

Street Address Address Line 2 City State ZIP Code

Relation to child*

Emergency Contact #2*

First Last

Daytime Phone*

Cell Phone*

Emergency Contact #2 Address*

Street Address Address Line 2 City State ZIP Code

Relation to child*

Medical Information

Physician's Name*

Phone Number*

Medical Insurance Provider:*

Policy #

Medication Information Please note that Trinity Preschool does not administer medication except in a case of emergency allergic reaction.

Please list any allergies and medications this child uses for allergies.

Please List Medications Taken (Type and Purpose)

Prescribing Physician's Name

Please list physical disabilities or special needs which may impair or limit service rendered to your child and special instructions related to those needs:

Parent Medical Form