Emergency Contact Information printable pdf download

CONTACT, MEDICAL, & EMERGENCY FORM

STREET OCALA, FL 34471  PO Box 670

512 SE 3

(352) 671-7700  (352) 671-7788

F R S (800) 955-8770  (800) 955-8771 (TTY)

This form is to be completed annually by parent/guardian ONLY. Please notify school of any changes in this information throughout the school year.

STUDENT INFORMATION

PLEASE PRINT LEGIBLY

Last Name:

First Name

Middle Name:

Jr., II, etc:

Birth Date:

Age:

Grade:

Residence Address:

Apt#:

City:

State:

Zip:

Mailing Address

Apt#:

City:

State:

Zip:

(if different)

PARENT/GUARDIAN INFORMATION:

Mother’s/Guardian’s Name:

Place of Employment:

Work Phone:

Address

Home Phone:

Cell Phone:

(If different from home address):

Father’s/Guardian’s Name:

Place of Employment:

Work Phone

Address

Home Phone:

Cell Phone:

(If different from home address):

ADDITIONAL STUDENT INFORMATION:



STUDENT LIVES WITH: (check one)

Both Parents

Mother

Father

Other: _________________________

(Attach any restraining order or similar judicial pleading that prohibits parental access. If a court-adopted parenting plan is in effect, attach a copy)

OTHER BROTHERS/SISTERS ENROLLED IN MARION COUNTY PUBLIC SCHOOLS

Name:_______________________________

Name:______________________________

Grade:________

Grade:_______

SPECIAL HEALTH PROBLEMS AND/OR NEEDS REQUIRING MEDICAL ASSISTANCE AT SCHOOL



Hemophilia

Asthma

Vision/Hearing/Speech

Diabetes

Other

____________________________

(Specify)



Seizure Disorder

Inhaler

Sickle Cell Disease or Trait

Prescribed Medication

(Specify)_______________________________________



Cystic Fibrosis

EpiPen

Medical Procedure

Allergies

(Specify)

____________________________________________________________

Medical Services needed at SCHOOL: Parent/Guardian authorization & physician order required______________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________ ________________________________________

SCHOOL USE ONLY: Rcvd by_____________________ date ________________ Reviewed by nurse ____________________ date __________ _____  comments on back:

CHILD PICK-UP/EMERGENCIES:

I agree that the school may release my child to the following people and provide pertinent information related to this release.

(1)Name:

Relationship :

Phone:

(2)Name:

Relationship:

Phone:

(3)Name:

Relationship :

Phone:

(4)Name:

Relationship:

Phone:

I understand and agree to the following:

●My child's records and information may be shared with the School Board's health care partners as needed to provide and evaluate health care services.

●If my child is or becomes Medicaid eligible, reimbursable services may be billed to Medicaid and my child's information and records may be provided to Medicaid and/or

the School Board's medicaid processing agents or the School Board's health care partners.

●In case of emergency, my child may be transported by Emergency Medical Services to a hospital and provided treatment, and I am responsible for charges related to the

transportation and medical treatment.

Parent/Guardian Name (Print): _________________________________________________________________________

Parent/Guardian Signature: ____________________________________________________________________________ Date __________________

SCHOOL USE ONLY:

School Name:

Entry Date:

School Year :

Student ID #:

Grade:

Ethnicity:

Race :

Sex Code: