Student Emergency Health Form - Dublin Unified School District
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1DUBLIN UNIFIED SCHOOL DISTRICT
Student Emergency Health Form
School Year: ______________
Student’s Name:
Grade:
Birthdate:
In 2015-16
Teacher:
Student ID:
Address:
Parent/Guardian:
Cell Phone:
Work Phone:
Home Phone:
1
Parent/Guardian:
Cell Phone:
Work Phone:
Home Phone:
2
Emergency Contact:
Cell Phone:
Work Phone:
Home Phone:
3
Emergency Contact:
Cell Phone:
Emergency Contact:
Cell Phone:
4
5
Physician’s Name:
Dentist’s Name:
Phone Number:
Phone number:
Hospital:
Insurance Carrier:
Policy ID:
Last Weight:
Medical Alert: The school must be aware of any health problems or conditions (i.e. allergies, asthma,
diabetes, seizures, recent surgeries, heart conditions, etc.) which may impact your child’s health and safety
at school.
:
Health Conditions
Medication at school:
My child does not need medication at school
Medication at home:
Allergies:
No known allergies
I give my permission to DUSD to inform school staff of my child’s health condition/problem:
Yes
No
Emergencies: In the event I cannot be reached, I hereby authorize Dublin Unified School District to arrange
for named doctors or dentist, ambulance or hospital facility to provide treatment to my child in case of
emergency, accident or illness.
Parent/Guardian Signature & Date
Parent/Guardian Signature & Date
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