Form 4710 - Student Emergency Contact Card (Page 2 of 2) in pdf

STUDENT EMERGENCY CONTACT CARD

Medical Information

EMERGENCY TREATMENT AUTHORIZATION

STUDENT

________________________________________________________________

_______

Last

First

Middle

Grade

I/we, the undersigned parent(s) of ________________

MEDICAL/HEALTH INFORMATION-

________________, do hereby give authorization and

consent to the school to obtain emergency medical care

Medication: Does your child take medication?

Yes

and necessary emergency transportation to a healthcare

facility

Medication

Dosage

Hour(s) given

______________________

_________

Parent Signature

Date

If your child requires medication at school, all medication sent to school must be in the original

prescription container with a current date and the child’s name. Also a “Medication/treatment

Authorization” form, must be completed and signed by the physician and the parent and must be on file.

RELEASE OF MEDICAL INFORMATION

Health Insurance Information: Please check appropriate box.

I hereby understand and authorize that my child’s

 Family Health Insurance

 Florida Healthy Kids

 Florida KidCare

 Other:_________

medical records or other medical information, furnished

 Medicaid# _________________________________

 No Health Insurance

to the school, will be shared with school officials and

emergency

personnel

who

have

legitimate

Physician/Health Care Provider

Phone No.

_______________________________

__________________

medical/educational purpose for accessing such medical

Health Plan/Group Name

Policy No.

____________________________________

__________________

records and information.

Dentist

Phone No.

_____________________________________________________

__________________

______________________________

__________

Vision and/or Hearing Information:

Parent Signature

Date

 Wears glasses/contacts:

YES/NO

 Wears hearing aid(s) YES/NO

Medical Conditions: Please check the appropriate boxes if your child has any of the

EMERGENCY DISMISSAL

following:

 Severe Allergies

 Food/Environmental

 Stinging Insects/Bees

 Medicines/Drugs

In the event of a severe storm or other unscheduled

 Other

emergency dismissal your child is instructed to:

Please explain: __________________________________________________________________________

 Walk Home

Requiring:

 Benadryl

 EpiPen

Other ______________________________

→

 Ride Public Transportation

 Asthma

If checked,

 uses inhaler

 on daily medication

 Ride School Bus as usual

 Seizures

If checked, on medication?

 Yes

 No

 Ride Home with parent only

 Diabetes

If checked, insulin dependent?

 Yes

 No

 Ride Home with friend identified on authorized

contact

 Movement limitations: __________________________________________________________________

list

 Other (please explain): __________________________________________________________________

 Recent illness, hospitalization or surgery. If checked, please provide date(s) and description(s):

______________________________

__________

_________________________________________________________________________________________

Parent Signature

Date

_________________________________________________________________________________________

Form 4710 Rev.

6/20/11

We recommend that you duplicate this card for your records.

Form 4710 - Student Emergency Contact Card Page 2

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