Student Emergency Card printable pdf download

STUDENT EMERGENCY CARD

Medical Alert

Berkeley Unified School District

Last Name

STUDENT First Name

Middle Name

Birthdate

Grade

Room Number

Teacher

Home Address (Not updated by school)

City

Zip

Mailing Address

City

Zip

PARENT - GUARDIAN

Parent 1/Guardian 1

Home Phone

Parent 2/Guardian 2

Home Phone

Daytime Phone

Cell Phone

Daytime Phone

Cell Phone

E-mail address

Employer Name/City

Does someone other than the Parent/Guardian provide afterschool care for your child?

Yes

LEARNS

BEARS

Other

Student takes the SCHOOL BUS

Name

Phone

Daily or: Mo Tu We Th Fr

afterschool

(circle days at afterschool)

EMERGENCY CONTACTS

List local emergency guardians who have agreed to take responsibility for picking up and providing either temporary or extended care of your

child in case of illness, minor injury or a natural disaster if a parent or primary guardian cannot be reached:

Name(s)

Phone

Alternate Phone

Relationship

Emergency third party phone contact outside of the Bay Area who can be contacted in the event of a local disaster:

HEALTH & MEDICAL

Health concerns:

Asthma

Allergies

Diabetes

Seizures

Other:

Medications to be taken at school require a physician-signed Medication Authorization Form. Forms are available from the school office or district website. List

all—including emergency—medications:

Physician

Phone

Address

Health Plan Provider

Member Number

Group Number

Dentist

Phone

Address

I, the undersigned legal parent or guardian of the student shown above, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical

diagnosis, or treatment and hospital care to be rendered under the general or special supervision and upon the advise of a physician, surgeon, or dentist under the provisions

of the Medical Practice Act, or Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care but is given

to provide authority and power for the physician/dentist to render care which in his/her best judgement may be deemed advisable. This authorization is given pursuant to the

provisions of Section 25.8 of the Civil Code of California.

It is the responsibility of the parent/guardian to immediately notify the school in writing of any changes in the information on this card. A new card must be

completed every school year.

PARENT/GUARDIAN SIGNATURE

DATE

Official Use Only

To be completed ONLY when releasing a child to an emergency guardian or medical personnel following a natural disaster.

Student released to

Date/Time

Student release coordinator's signature

0000000 BUSD Student Emergency Card (Revised 04/22/2014) Page 1 of 2