Student Emergency Medical Form Page 2
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1
2Does child have Health Insurance?
YES________ If YES, name of insurance company __________________________________________________________________________________________________
NO ________ If NO, NJ Family Care provides free or low cost health insurance for uninsured children and certain low income parents.
For more information call 800-701-0710 or visit
to apply online.
You may release my name and address to the NJ Family Care Program to contact me about health insurance.
SIGNATURE: ____________________________________ PRINT NAME: __________________________________________
DATE: _________________________
Written consent required pursuant to 20 U.S.C.
1232g (b)(1) and 34 C.F.R. 99.30 (b).
Dental Exam
______________ _____________
Eye Exam
______________
___________
__________________
Date
Braces(Y/N)
Date
Contacts(Y/N)
Glasses(Y/N)
Allergy
__________________________
______________________________________________________________________________
Kind
Medications
Allergic Reaction
__________________________
______________________________________________________________________________
Date
Medications
Tetanus Immunization
__________________________
_____________________________
Date
Vaccine type (Td or Tdap)
Restrictions
__________________________________________________________________________________________________________________
Type
LIST ANY MEDICAL/SURGICAL CARE YOUR CHILD HAS RECEIVED DURING THE PAST YEAR: ____________________________________________
________________________________________________________________________________________________________________________________________________________
I GIVE CONSENT TO THE HEALTH SERVICES DEPARTMENT TO:
Yes
No
-Share my child’s health information including medications with my child’s teachers and other appropriate school personnel
-Screen for Scoliosis (GRADES 5,7,9,11)
Please list other children attending Westfield Public Schools (Name, School) ____________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
PARENT/GUARDIAN AUTHORIZATION: MUST BE SIGNED AND RETURNED TO YOUR CHILD’S SCHOOL
I, THE UNDERSIGNED, DO HEREBY AUTHORIZE OFFICIALS OF NEW JERSEY PUBLIC SCHOOLS TO CONTACT DIRECTLY THE PERSONS NAMED ON THIS
CARD AND DO AUTHORIZE THE NAMED PHYSICIANS TO RENDER SUCH TREATMENT AS MAY BE DEEMED NECESSARY IN AN EMERGENCY, FOR THE
HEALTH OF SAID CHILD.
IN THE EVENT THAT PHYSICIANS, OTHER PERSONS NAMED ON THIS CARD, OR PARENTS CANNOT BE CONTACTED, THE SCHOOL OFFICIALS ARE
HEREBY AUTHORIZED TO TAKE WHATEVER ACTION IS DEEMED NECESSARY IN THEIR JUDGEMENT, FOR THE HEALTH OF THE AFORESAID CHILD.
I WILL NOT HOLD THE SCHOOL DISTRICT FINANCIALLY RESPONSIBLE FOR THE EMERGENCY CARE AND/OR TRANSPORTATION FOR SAID CHILD.
____________________________________________________________________________________
SIGNATURE PARENT/GUARDIAN
DATE
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