Form 4172 - Student Emergency Contact Card - 2015 Page 2
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1
2Broward County Public Schools
Student Emergency Contact Card
The personal information you provide on this form will be kept confidential (in a protected area)
and only used and disclosed by school staff on a need-to-know basis.
Student Name
Last
First
Middle
If your child requires medication at school, all medication sent to the school must
Does your child
be in original prescription container with a current date and the child’s name. Also
No
Yes
take medication?
a “Medication/treatment Authorization” form, must be completed and signed by
the physician and the parent and must be on file at the school.
Medication
Medication
Dosage
Hour(s) Given
Please check appropriate
Health Insurance
Family Health Insurance
Florida Healthy Kids
Florida Kid Care
box:
Information
Medicaid #
No Health Insurance
Other
Does your child wear
Does your child wear
Vision and
No
No
Yes
Yes
contacts/glasses?
hearing aid(s)?
Hearing
Name
Phone Number
Physician
Health Care
Providers
Dentist
Health Plan/Group Name
Check all that apply:
Asthma
If checked, uses inhaler?
Yes
No
On daily medication?
Seizures
If checked, on medication?
Yes
No
Diabetes
If checked, insulin dependent?
Yes
No
Movement Limitations
Recent illness/hospitalization/surgery (describe)
Medical Conditions
Other
Severe allergies? If checked, please specify:
Food/environmental
Allergies require:
Insect stings/bees
EpiPen
Medicines/Drugs
Benadryl
Other
Other
I hereby understand and authorize that my child’s medical records or other medical information, furnished to the school, will be shared
Release of Medical
with school officials and emergency personnel who have a legitimate medical/educational purpose for accessing such medical records and
Information
information.
Parent Signature
Date
Emergency
The school will call for emergency medical care as deemed necessary. Emergency transportation to a health care facility, as
Treatment
determined by paramedics, will be authorized.
REGULAR DISMISSAL PROCEDURES
EMERGENCY DISMISSAL PROCEDURES
On a typical school day, how will your child leave school?
In the event of a severe storm or other unscheduled emergency
dismissal your child is instructed to:
Ride in car
Ride School Bus
Dismissal
Walk/bike home
Attend on-site after-care
Walk home
Ride school bus as usual
Information
program
Ride public transportation
Ride home with
Ride public
Attend off-site after-care
friend as indicated on
Ride home with parent only
transportation
program
authorized contact list
Please list any siblings at our school
Please list any other languages spoken at home:
Last Name
First Name
Grade Level
Siblings and
Home Language
Please assist us in better understanding the needs of our school community by answering the following questions.
Please check all that apply.
Does your child have access to a computer in your home?
Yes
No
Survey Questions
Do you have home internet access?
Yes
No
Does your child have access to the internet on your home computer?
Yes
No
Do you have internet access outside your home?
Yes
No
Please indicate the method of contact you prefer:
Email
Text
Phone
Form 4172 Revised 05/13
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