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School Date
Grade Room Language Spoken at Home
Name Sex: M
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F
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Birthdate
Home Address Apt. No. City Zip Code
Mailing Address Zip Code Child resides with
(Last) (First) (Middle Initial)
Month Day Year
EMERGENCY CONTACTS: In case child listed above becomes ill or is injured at school and I cannot be contacted, the school authorities have my
permission to contact and release my child to the custody of one of the following:
Name Relationship Phone
1.
2.
Family Physician Phone Dentist Phone
EMERGENCY CARD
(This card needs to be completed every school year.)
Student Address Label
Father’s/Legal Guardian’s Name:
Employer:
Active Duty: Yes
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No
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Branch of Military Service:
Home Phone: Bus. Phone:
Cellular Phone:
E-mail Address:
Mother’s/Legal Guardian’s Name:
Employer:
Active Duty: Yes
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No
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Branch of Military Service:
Home Phone: Bus. Phone:
Cellular Phone:
E-mail Address:
If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one.
To assure prompt attention to your child,
PLEASE NOTIFY SCHOOL OF ANY CHANGE IN PHONE NUMBER OR ADDRESS.
RS 17-1251, May 2017 (Rev. of RS 13-1113)
Note: Please complete health information on back of card.
Æ
Parent’s/Legal Guardian’s Signature
By entering your initials on the signature line, you are attesting that
you agree to the above conditions and it replaces your signature.
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OTHER HEALTH CONCERNS:
Other children:
Name School Grade
My child has health insurance:
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Yes
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No If YES, check:
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QUEST/Medicaid OR
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Private
If private, check your plan:
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HMSA
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Kaiser
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Tri-Care
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Other
INSURANCE INFORMATION:
MEDICAL CONDITIONS:
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My child does not have any medical conditions.
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My child has a medical condition(s).
Please check below:
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Chronic Cough/Wheezing
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Hearing Problems
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Asthma
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Blood Disorders
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Bone/Joint Disorders
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Diabetes Type II
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Cancer/Leukemia
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Diabetes Type I
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Genetic Condition
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Heart Condition
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High Blood Pressure
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Metabolic Disorder
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Seizures
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Skin Problems
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Vision Problems
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Other
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ALLERGIES:
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Bee Sting
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Food
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Medications
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Other
For the above allergy(ies), reaction occurs by:
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Skin contact
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By inhalation
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By ingestion
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Other
Date of last reaction:
Describe the allergic reaction that occurs:
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MEDICATION(S) TAKEN:
My child takes the following medication(s):
Reason for taking the medication(s):