Student Data Collection Form (Page 2 of 2) in pdf

STUDENTS

09.14 AP.2

)

ONTINUED

Student Data Collection Form

EMERGENCY INFORMATION

Is your child on any routine medication?  Yes

 No

If yes, please list below:

_____________________________________________________________________________

Does your child have allergies (such as allergic to medication(s) or insect bites?  Yes

 No

If yes, please specify _____________________________________________________________

Does your child have a history of  heart disease,  diabetes,  T.B.,  nervous disorder,



epilepsy,  ear infection,  seizure,  asthma,  Other _____________________________

If so, please check and describe any special emergency treatment that may be required:

______________________________________________________________________________

Please list any regular medications your child currently takes: ____________________________

Doctor’s Name: ____________________________________ Phone Number: _______________

Address: ______________________________________________________________________

In case of emergency, accident, or serious illness of the above named child, I request the school to

contact Guardian 1 or Guardian 2 listed on this form. If school personnel are unable to contact

Guardian 1 or Guardian 2, I hereby authorize them to call the person(s) listed below:

Name (First, Middle, Last)

Relationship

Phone Number

*Anyone picking up a child from school must be prepared to present a photo I.D.

Are there court orders concerning the custody and/or visitation of your child?  Yes

 No

 If yes, have you provided the school with an official copy of the legal documents to

place in your child’s folder?

 Yes

 No

*Legal documents must be on file in order to permit or deny a parent the right to pick his/her child up from school.

EARLY DISMISSAL

In the event of early dismissal, your child will follow normal daily transportation methods unless

specified otherwise. When school is dismissed early for any reason, I would prefer the following:

 My child will ride the bus home

 My child will be picked up at school in a timely manner

 Other: ______________________________________________________________________

I swear or affirm that to the best of my knowledge or belief, the statements and information

contained above are true, factual, and complete. If it is impossible to contact the physician named

above, I hereby authorize the school to take action necessary to maintain the student’s health.

_______________________________

___________________________

Parent/Guardian’s Signature

Date

Review/Revised:6/28/10

Page 2 of 2

Student Data Collection Form Page 2

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