Fillable Emergency Card Form printable pdf download

EMERGENCY CARD

Special Health Alert: _______________________________________________________________________________

Student Name: _____________________________________ D.O.B.: _____________ Grade: ______ Sex: M

Last

First

Check if contact information has changed since last year

Mother/Guardian

Father/Guardian

(Check box if same as mother)

Name (Last, First)

Address

(Street, City and Zip)

Home Phone #

Cell Phone #

Employer and phone #

Child Lives with:

Both parents

Mother

Father

Step Mother

Step Father

Guardian/Other:__________________

ALTERNATE CONTACTS

Please list 3 people over the age of 18 who we can contact and release your student to if we are unable to reach either parent/guardian

Name

Contact numbers

Relationship to student

In addition, please list an out-of-state person and phone number in case of a disaster:

In case of disaster (check one)

Keep my child at school OR

Release my child to any of the people listed

Siblings

School

Student’s physician:

Last physical exam:

Insurance company:

MEDICAL INFORMATION

Check only those that apply and return to school office

No medical concerns

Asthma

Requires medication/inhaler

Yes

Daily

As needed

With exercise

Name of medication _____________________________

Given at school?

Yes

Allergic reactions

To what? ______________________Hives/rash

Yes

Breathing difficulty?

Yes

(severe)

Uses Benadryl

Yes

Has epi-pen?

Yes

Diabetes

Type I

Type II

Medications:

Oral

Injection

Pump

Given at school?

Yes

Seizure disorder

Date of last seizure ____________________________

Requires medication?

Yes

Name of medication ___________________________

Physician ___________________________

Heart problems

Diagnosis: ___________________________________

Physical restrictions

Yes

Hospitalization

Date/Explain: __________________________________________________________________________

(ER visits)

Assistive Devices

Corrective shoes/braces

Crutches

Wheelchair/scooter

Glasses

Hearing aides

Taking Medication

For what condition: _____________________________________________________________________

Given at school?

Yes

Please list any other important health information: ________________________________________________________________

If my child suffers a serious injury or illness, I understand first aid will be rendered in accordance with local school practices.

If neither my alternate nor I can be reached by phone, please call the doctor listed or transport my child to any available

medical facility. I am aware that in most situations the physical/medical facility will not treat a minor child without parent

permission. I understand that the school assumes no financial responsibility for medical care or transportation.

Signature: _____________________________________________________________ Date: ___________________

Rev 1/16

Emergency Card Form

Related Articles

Related forms

Related Categories