Fillable Emergency Contact Form

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Emergency Contact Form

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The Emergency Contact Form form is 2 pages long and contains:

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  • 63 check-boxes
  • 123 other fields

Country of origin: OTHERS
File type: PDF

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For Office Use Only: □ Medical
School #: □ Court Order
Student #: □ Special Needs
Date Enrolled:
□ Other
First: Middle:
Gender: □ Male □ Female
Grade Level:
City, State, Zip: Home Phone:
City, State, Zip: Student Cell Phone:
Student lives with: Student Email:
Has student changed address since last
registration?
Is there a court order on file that prevents a parent
from having contact with the student?
□ Yes □ No □ No □ Yes, contact school
First: Cell Phone:
City, State, Zip: Home Phone:
Work Phone: Parent email:
First: Cell Phone:
City, State, Zip: Home Phone:
Work Phone: Parent email:
Relationship: Phone:
Date: Relationship:
Relationship: Phone:
Date: Relationship:
Authorized Release/Contact
Non-Registering Parent
Authorized Release/Contact
Student Information
Registering
Parent
Student:
Student Identification Number:
Grade:
Other
Parent
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.
Last Name:
Teacher (elementary school only):
Home Address:
Mailing Address (If different from above):
Signature:
Check any that apply to student residence:
Date of Birth: / /
□ Medical □Court Order □Special needs □Other
Last Name:
Home Address (if different from student):
Employer:
Last Name:
Home Address (if different from student):
Employer:
Broward County Public Schools
This form shall be updated every year
Student Emergency Contact Card
Please list the names of persons to whom we may release your child or whom we may contact if we cannot reach you. NO STUDENT WILL BE RELEASED
TO ANYONE OTHER THAN THE PERSONS LISTED BELOW. In selecting someone to whom you authorize the release of your child, consider whether this
person is prepared to handle any special medical needs required by your child. I/We hereby authorize contact with, release of emergency related
information, or release of the student to the following persons in the event of illness, evacuation, or other emergency that may occur while the student
is in school.
Name:
I declare that the information on this card is true and correct. I will notify the school office immediately of any changes.
I declare that the information on this card is true and correct. I will notify the school office immediately of any changes.
Signature:
This section may be completed only by the non-registering parent in order to designate additional persons who may pick up the student. The registering
parent may not alter this section of this card. The non-registering parent may not alter any other portion of this card.
Name:
Form 4710 Revised 11/18
2345
First: Middle:
Dosage: Hour(s) Given:
Phone:
Phone:
Phone:
Allergies require:
□ EpiPen
□ Benadryl
□ Other:
Date:
□ Ride in Car □ Ride School Bus □ Ride Public Transportation
□ Attend ON-site after-care program □ Attend OFF-site after-care program □ Walk or Bike ride home
□ Walk home □ Ride School Bus as usual □ Ride Public Transportation
□ Ride home with parent only
First Name: Grade level:
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Health
Insurance and
Providers
Please check appropriate box: □ Family Health Insurance □ Florida Kid Care □ Florida Healthy Kids □ None
If NONE, do we have your permission to forward the parent's name and phone number to Florida Kid Care Insurance for health insurance screening to
see if you may be eligible for health insurance coverage? If Yes, please sign here:
Broward County Public Schools Student Emergency Contact Card
Medication
Information
Does your child take medication?
□ Yes □ No
If your child requires medication at school, all medication sent to the school must be in the
original prescription container with a current date and the child's name. Also, 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:
Student Last Name:
Physician:
Dentist:
Health Plan/Group name:
Medical Information
□ Asthma. If checked, uses inhaler?
□ Seizures. If checked, on medication?
□ Diabetes. If checked, insulin dependent?
□ Movement limitations (specify):
□ Recent illness/hospitalization/surgery (describe:
□ Severe Allergies. If checked, specify Type:
Does your child wear glasses/contacts? □ Yes □No Does your child wear hearing aid(s)? □ Yes □ No
Please check all that apply:
□ Yes □ No □ On daily medication
□ Yes □ No
□ Yes □ No
□ Food/environmental:
□ Insect stings/bites:
□ Medicines/Drugs:
Medical Conditions
Release of Medical
Information and Emergency
Treatment
I hereby authorize for my child’s medical information, parental contact information, and other health information (collected from health services
provided at school, including information stored electronically) to be shared with emergency personnel and health department officials to address
conditions of public health importance, including information to meet and to prepare for potential or confirmed health conditions. For students
receiving health services from school or District staff and/or contracted partners, I also authorize the District to share my child's identifiable health
information and related demographics with the Florida Department of Health to conduct monitorings to assure program compliance by the District and
schools, and assess the delivery of services.
Medical and other information will be disclosed without consent from the parent/eligible student in case of health emergencies, as permissible by the Family Educational Rights
and Privacy Act (FERPA). The school will call for emergency medical care as deemed necessary. Emergency transportation to a health care facility, as determined by
paramedics, will be authorized.
Dismissal
Information
□ Ride home with person indicated on authorized contact list
Emergency Dismissals Procedures. In the event of a severe storm or other unscheduled emergency your child is instructed to:
Regular Dismissals Procedures. On a typical day, how will your child leave school?
Parent Signature:
Siblings and
Home Language
Last Name:
Please list any other languages spoken at home:
Survey
Questions
Please assist us in 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?
Do you have home internet access?
Does you child have access to the internet on your home computer?
Do you have internet access outside your home?
Please indicate the method of contact you prefer: □ Phone call □ Text □ Email
Form 4710 Revised 11/18
2345
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Emergency Contact Form

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Completed 18 August 2020

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