School Date
Grade Room Language Spoken at Home
Name Sex: M
q
F
q
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
q
No
q
Branch of Military Service:
Home Phone: Bus. Phone:
Cellular Phone:
E-mail Address:
Mother’s/Legal Guardian’s Name:
Employer:
Active Duty: Yes
q
No
q
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.
q
OTHER HEALTH CONCERNS:
Other children:
Name School Grade
My child has health insurance:
q
Yes
q
No If YES, check:
q
QUEST/Medicaid OR
q
Private
If private, check your plan:
q
HMSA
q
Kaiser
q
Tri-Care
q
Other
INSURANCE INFORMATION:
MEDICAL CONDITIONS:
q
My child does not have any medical conditions.
q
My child has a medical condition(s).
Please check below:
q
Chronic Cough/Wheezing
q
Hearing Problems
q
Asthma
q
Blood Disorders
q
Bone/Joint Disorders
q
Diabetes Type II
q
Cancer/Leukemia
q
Diabetes Type I
q
Genetic Condition
q
Heart Condition
q
High Blood Pressure
q
Metabolic Disorder
q
Seizures
q
Skin Problems
q
Vision Problems
q
Other
q
ALLERGIES:
q
Bee Sting
q
Food
q
Medications
q
Other
For the above allergy(ies), reaction occurs by:
q
Skin contact
q
By inhalation
q
By ingestion
q
Other
Date of last reaction:
Describe the allergic reaction that occurs:
q
MEDICATION(S) TAKEN:
My child takes the following medication(s):
Reason for taking the medication(s):
