□ 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
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
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.
□ 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
Release of Medical
Information and Emergency
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.
□ 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?
Please list any other languages spoken at home:
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