In Case Of Emergency (ICOE) Form

Student Name*

First Last

Date of Birth

Gender

Emergency Contact*

First Last

Relationship*

Emergency Contact Email*

Emergency Contact Phone*

Alternate Emergency Phone

Name of Primary Physician

Physician Phone

Please check if the student has had any of the following conditions or considerations:

If there is anything current or ongoing about the student's health, mental outlook, processing skills, or behavior that has been specifically helpful at school (or at home) please offer our teaching team the opportunity to benefit from that knowledge. Disclosed information is confidential, used only to assist the instructor with developmental needs in the classroom:

Are the student’s immunizations up to date?*

(No need to submit medical records)

Yes
No

Is the student taking any medications regularly?*

Yes
No

If yes, list the medication(s) the student is taking:

Is the student allergic to any medication?*

Yes
No

If yes, list the medication(s) the student is allergic to:

Does the student have any other allergies (foods, bee stings, etc.)?*

Yes
No

If yes, list the other allergies:

Does the student carry an EpiPen, Inhaler, or other emergency rescue device?*

Yes
No

If yes, list the emergency device(s), and anything we should know:

If the Student has a headache, would you like the BTC office to administer the following?*

Acetaminophen (Tylenol)
Ibuprofen (Advil)
Do Not Administer

Any Additional Message for BTC?

Permission for Emergency Treatment/Verification

I affirm that the information provided on this form is complete and accurate to the best of my knowledge.

Parent/Guardian signature*

Today's Date*

Broadway Training Center of Westchester

Developing Character On and Off Stage

Developing Character On and Off Stage

Permission for Emergency Treatment/Verification