Student Health
Identification Card
Medical conditions
Doctor phone #
Dentist phone #
Parent/Guardian
Phone/cell #
Contact person #2
Phone/cell #
Location to meet if separated
Family Member
Family Member
Family Member
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Blood Type
Allergies
Prescription Medications
Blood Type
Allergies
Prescription Medications
Blood Type
Allergies
Prescription Medications
Medical conditions
Medical conditions
Medical conditions
Work/school phone #
Work/school phone #
Work/school phone #
Photo
Photo
Photo
7280 New York State Department of Health 7/10
Your Family Name:
Date:
/
/
Health
Emergency
Card
Important Phone Numbers
Important Phone Numbers
Family Member
Family Member
Main contact person
Out-of-state contact #2
Phone/cell
Place family meets, if separated
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Blood Type
Allergies
Prescription Medications
Blood Type
Allergies
Prescription Medications
Medical conditions
Medical conditions
Work/school phone #
Work/school phone #
Phone/cell
Contact person #2
Phone/cell
Out-of-state contact
Phone/cell
Physician
Hospital
Pediatrician
Dentist
Pharmacist
Medical Insurance
Veterinarian/Kennel
Other
Photo
Photo
Student Health
Identification Card
Fill out and detach. Keep in child’s backpack.
Name
Cell #
DOB / /
Hair Color
Eye Color
Unique physical traits (e.g., birth marks)
Blood Type
Allergies
Prescription Medications
My photo here