2008/09

SPOFFORD POND SCHOOL

31 Spofford Road
Boxford, Massachusetts
(978) 352-8616

CONFIDENTIAL Staff Health/Emergency Form CONFIDENTIAL

Name:
Address:

Home Tel: ( ) Cell Tel: ( )

Physician: Address: Tel: ( )

Hospital: Address: Tel: ( )

Dentist: Address: Tel: ( )

For your safety, please list any health conditions/needs (asthma, allergies, diabetes, high blood
pressure, headaches, low blood sugar, heart conditions, etc.) with the nurse in the Health
Office. PLEASE list the prescribed medication(s) you are taking for the condition and WHERE
YOU KEEP THIS MEDICATION DURING THE DAY. This information will allow the nurse to have
immediate access to your medication in the event of an emergency.

Allergies:

 Check if you had Chicken Pox or the vaccine.

In the event of an emergency, please notify:

1) Name: Relationship:
Home Address: Tel: ( )

Work Address: Tel: ( )

IMPORTANT: Cell Tel: ( )

2) Name: Relationship:
Home Address: Tel: ( )

Work Address: Tel: ( )

IMPORTANT: Cell Tel: ( )