Student Emergency Form
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1STUDENT EMERGENCY FORM
Date ______________
Room ______
Teacher ___________________
(Return to School Office)
HEALTH CONDITIONS:
(check box)
!
!
Student’s Name: _________________________________________________________________
Asthma
Bee Sting Allergy
!
!
Diabetes
Seizures
!
!
Birth Date:
Sex:
Male
Female
Grade _________
!
Food/Medication Allergy
_________
(please list)
month
day
year
Home Address: __________________________________________________________________
_______________________________________
!
Parent/Guardian Name: ____________________________ Relationship ____________________
Other
______________________
(please explain)
Phone #s: Home: ____________________ Cell : ______________ Work: _________________
_______________________________________
!
!
!
!
Child lives with:
Mother
Father
Caregiver/Guardian
Other __________________
Other children/siblings at this school:
(list name and grade)
Language spoken at home: _________________________________________________________
1. _________________________________________
EMERGENCY CONTACT NUMBERS
: In case of emergency, illness, or accident to the
2. _________________________________________
child named above, the school is authorized to process as indicated.
3. _________________________________________
Contact #1: Name: ______________________________________________________________
Relationship to student: ______________________
Address: (If different from home above) __________________________________
Phone:
________________________
(home, work, cell)
Contact #2: Name: ______________________________________________________________
Relationship to student: ______________________
Address: (If different from home above) __________________________________
Phone:
________________________
(home, work, cell)
Contact #3: Name: ______________________________________________________________
Relationship to student: ______________________
Address: (If different from home above) __________________________________
Phone:
________________________
(home, work, cell)
My child should never be released to the following: _________________________________________________________________________________
If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for school authorities to take appropriate
action for the safety and welfare of my child.
_______________________________________________________________________________
______________________________
Signature of Parent/Guardian
Date
Cleveland Municipal School District
EMERGENCY DATA FORM
Student’s Name: ________________________________________________________________________________________________
Address: __________________________________________________________________ Phone Number: _____________________
School: _________________________________________________________ Room: _________________
The following is required by Section 3313.712 of the Ohio Revised Code.
EMERGENCY MEDICAL AUTHORIZATION
Purpose – to enable parents and guardian to authorize the provision of emergency treatment for children who become ill or injured while
under school authority, when parents or guardians cannot be reached.
ALL BLANK SPACES MUST BE FILLED IN
In the event reasonable attempts to contact me at ____________________
(phone) or _________________________________ (other
parent) at _______________________ (phone) have been unsuccessful school personnel will call 911.
FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS BEING TAKEN, AND ANY PHYSICAL
to which a physician should be alerted.
IMPAIRMENTS
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Family Physicians: ______________________________________ Address: ____________________________________
Phone: _______________
______________________________________________________________________________
__________________________________________
Signature of Parent or Guardian
Date
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