1. Student and Family Information

Parent/Guardian 1

Parent/Guardian 2

Emergency Contact 1:

Emergency Contact 2

Medical Profile

Describe each condition, typical symptoms, triggers, restrictions, and required response:

Food, Snack, and Lunch Safety

Do not send prescription, nonprescription, or emergency medication until Homework Hub has approved the arrangement in writing. Any medication kept or administered during program hours may require current written directions from the student's licensed health care provider and must be supplied in the original labeled container.

Medication During Program Hours

Medication 1

Medication 2

Additional Medication:

Individual Safety and Support Needs

Emergency Action Plans and Supporting Documents

Emergency Care Authorization

If my child becomes ill or injured, I authorize Homework Hub personnel to provide basic first aid within the scope of their training, contact me and the emergency contacts listed on this form, and contact 911 or emergency medical services when staff determine that prompt medical attention may be necessary. If I cannot be reached, I authorize emergency medical personnel to evaluate, transport, and arrange treatment for my child. I understand that emergency medical professionals determine the care provided and that I am responsible for costs associated with emergency evaluation, transport, and treatment.

Parent/Guardian Acknowledgments

A parent or legal guardian must sign below. Please review this form at least annually and whenever the student's medical or safety information changes.