Student Emergency Form for Academic Year

Instructions: Submit one form per student.

Last Name
First Name
Street Address
Zip Code
Mother's Name
Mother's Email
Mother's Address (if different from child)
Mother's Cell Phone
Mother's home phone
Mother's work phone
Father's Name
Father's Email
Father's Address (if different from child)
Father's Cell Phone
Father's home phone
Father's work phone


In case of emergency, please contact the following (after trying the parents):

Name #2
Relationship #2
Phone #2
Name #3
Relationship #3
Phone #3

Health Information

Prescription medication (including asthma inhalers and Epipens) will NOT be administered by the staff of Rockbridge Academy without written permission from a parent AND a physician's signed order on file.  Please fill out the Permission to Administer Medication form and either mail it to Rockbridge Academy (911 Generals Highway, Millersville, MD 21108) or bring it to the first class with your child.

Please list any health problems that your child(ren) may have and any treatment that may be required (i.e., allergies, asthma, etc.).

Health information
Pediatrician's Name
Pediatrician's Phone
Hospital Choice (if choice is offered)

Medication Permission


The only over-the-counter medication that we will administer is Tylenol®.  Please refer to the Medication Distribution section of the Parent/Student Handbook on page 28 for further information about Rockbridge Academy's policies.

If your child is given Tylenol®, you will be notified via email.

Please indicate below whether or not you give Rockbridge Academy permission to give your child Tylenol®, either as-needed or by calling a parent first.

Permission to Administer Tylenol®
Child's Weight

Other Medication

If your child may require an inhaler, an EpiPen®, or Benadryl®, parents must provide this medication to the officeIn addition, parents must fill out the Permission to Administer Medication form, found in RenWeb under Resource Documents.

Please check all of the following that pertain:

Expiration date(s) for all medication submitted to Rockbridge Academy:

Emergency Medical Care Permission

I consent and authorize Rockbridge Academy, its faculty and staff to consent on my behalf and on behalf of my child to emergency medical care and treatment in the event I am unable to be notified by reasonable attempts of the need for such emergency medical care and treatment.

Permission to Administer Emergency Medical Care

Permission to Take Student Off Grounds

I give permission to the Rockbridge Academy staff to take my child off grounds only in an emergency situation.  Such action would be warranted if, for example, my child were left at school due to my inability to pick him or her up in a timely fashion.  The Rockbridge Academy staff member may take my child to the staff member’s home.  (This would occur only after all other emergency contacts have been exhausted.)

Permission to Take Student off Grounds

Other Information

Please list any other information about your child we should know.

Other information