Fillable Student Emergency Information (Montgomery Schools)

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Student Emergency Information (Montgomery Schools)

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MCPS Form 565-1
July 2020
Page 1 of 2
INSTRUCTIONS: Please complete both sides of this form and return to your child’s school as soon as possible.
Student Name (Last, First, Middle) Student’s Identified First Name
Student ID Grade Section Homeroom Teacher
Primary Phone Date of Birth GRADES 6–12 ONLY
YRBS/YTS
(see reverse)
o May NOT Participate
GRADES 11 AND 12 ONLY
o Do Not Release Contact Information to Military Recruiters.
Home Address
Language Spoken at Home
Preferred Language for Correspondence o English o Chinese
o French o Korean o Spanish o Vietnamese o Amharic
Bus Route #
Custody Concerns o
Yes
o
No (If yes, Contact School)
Is the student a dependent of a member of the active duty forces (full-time) Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or
Reserve Forces (Army, Army National Guard of the U.S., Air National Guard of the U.S., Navy, Air Force, Marine Corps, or Coast Guard)?
o Yes o No
Name of Parent/Guardian Living at Student’s Home Address Noted
Above. (Last, First, MI) (Contact First)
Name of Parent/Guardian Living at Student’s Home Address Noted
Above. (Last, First, MI)
Work Phone Cell Phone Work Phone Cell Phone
E-mail E-mail
Relationship to Student o Mother o Father o Guardian
o Other (Specify)
Relationship to Student o Mother o Father o Guardian
o Other (Specify)
Name of Parent/Guardian NOT Living at Student’s Home Address Noted
Above. (Last, First, MI)
Name of Parent/Guardian NOT Living at Student’s Home Address Noted
Above. (Last, First, MI)
Home Address of this Adult Home Address of this Adult
Work Phone Cell Phone Work Phone Cell Phone
Home Phone E-mail Home Phone E-mail
Relationship to Student o Mother o Father o Guardian
o Other (Specify)
Relationship to Student o Mother o Father o Guardian
o Other (Specify)
Person/Organization Responsible for Student Before School—Name (Last, First) (If other than parents/guardians noted above)
Address
Home Phone Cell Phone E-mail
Work Phone Relationship to Student (if any)
Person/Organization Responsible for Student After School—Name (Last, First) (If other than parents/guardians noted above)
Address
Home Phone Cell Phone E-mail
Work Phone Relationship to Student (if any)
Emergency Contacts: In an emergency that requires the school to release student using parent/child reunification protocols, and when parents/
guardians and other responsible adult(s) already listed cannot be reached, the school may release the student to these individuals.
Emergency Contact #1: (Last, First) Relationship to Student
Home Phone Cell Phone Work Phone E-mail
Emergency Contact #2: (Last, First) Relationship to Student
Home Phone Cell Phone Work Phone E-mail
Emergency Contact #3: (Last, First) Relationship to Student
Home Phone Cell Phone Work Phone E-mail
continued on page 2
Student Emergency Information
Office of Student and Family Support and Engagement
Montgomery County Public Schools
Rockville, Maryland 20850
CLEAR FORM
MCPS Form 565-1
Page 2 of 2
For Students in Grades 6 through 12 ONLY
Information to Parents/Guardians of Middle School and High School Students Regarding the
Maryland Youth Risk Behavior Survey/Youth Tobacco Survey
This section of the form is to notify you about the Maryland Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) and procedures to follow if you DO NOT
want your child to participate in the YRBS/YTS.
Your child’s school may be taking part in the YRBS/YTS, conducted by the Maryland Department of Health (MDH) in collaboration with the Maryland State Department
of Education (MSDE) and the Centers for Disease Control and Prevention (CDC). The survey was designed by the CDC to identify risk behaviors that may include safety
behaviors such as use of helmets and seat belts, depression and mental health; use of tobacco, alcohol, or other drugs; nutrition and physical activity; and sexual behavior.
The survey has been designed to protect your child’s privacy. The survey is confidential and students will not put their names on the survey. No school or student
will ever be mentioned by name in a report of the results.
The survey is voluntary. If your child is not comfortable answering a question, your child may skip it. No action will be taken against the school, you,
or your child, if your child does not take part. In addition, students may stop participating in the survey at any point without penalty.
If you have any questions about your child’s rights as a participant in this survey, or if you feel your child will be harmed in any way by taking part, please call toll-free
1-877-878-3935, leave a message including your name and phone number, and someone will call you back as soon as possible. For more information about the survey,
please visit www.cdc.gov/HealthyYouth/.
If you DO NOT want your child to take part in the survey, (1) please complete the section on the front of the form which indicates “YRBS/YTS—
May Not Participate,” (2) return your child’s Student Emergency Information form to your child’s school.
FREQUENTLY ASKED QUESTIONS
Q. Why is the Maryland Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) conducted?
A. The MDH and the MSDE will use the results from the YRBS/YTS to (1) monitor how priority health risk behaviors among middle and high school students change
over time; (2) evaluate the impact of broad state and local efforts to prevent health risk behaviors; and (3) improve school health education policies and programs.
Q. Are sensitive questions asked?
A. Some questions may be considered sensitive by some districts, schools, or parents/guardians. All such questions are presented in a straightforward and sensitive
manner and were designed by the CDC. Topic areas covered include use of helmets and seat belts; depression and mental health; use of tobacco, alcohol, other
drugs, nutrition and physical activity; and sexual behavior.
Q. Will student names be used or linked to the surveys?
A. No. The survey is designed to protect your child’s privacy. The survey is administered by specially trained field staff. Students do not put their name on the survey.
When students finish the survey, they place the completed survey in a large box or envelope.
Q. Are students tracked over time to see how their behavior changes?
A. No. Students who participate cannot be tracked because no identifying information is collected.
Q. How are children picked to be in the survey?
A. Statewide, approximately 360 schools and 85,000 students are picked to take part. First schools are randomly picked, and then classrooms in selected schools are
randomly picked. Every student in a selected class may participate.
Physician/Authorized Health Care Provider Name
Physician/Authorized
Health Care Provider Phone
Dentist/Hygienist Name Dentist/Hygienist Phone
Health Insurance o Yes o No (If yes, check one) o Private o Health Choice (Medical Assistance) o Care for Kids
School officials will administer first aid and/or take your child to a physician or hospital for emergency treatment in the event it appears necessary and parents/
guardians or other responsible adults noted on this form cannot be contacted. (The rescue squad will be used as deemed necessary in emergency situations.)
Does the student have an allergy to bee stings? o Yes o No (If yes, please provide additional information such as reaction description, medication, etc.)
Does the student have an allergy to any foods and/or medications? o Yes o No (
If yes, please provide additional information such as reaction description, medication, etc.)
Does the student have any other allergies? o Yes o No (
If yes, please provide additional information such as allergen, reaction description, medication, etc.)
Does student self-carry an Epinephrine Auto-Injector? o Yes o No (If yes, MCPS Form 525-14 must be completed and returned to the school)
Does student self-carry any other emergency medication (e.g., Asthma Inhaler)? o Yes o No
(If yes, MCPS Form 525-13 must be completed and returned to the school)
Are there any other medical considerations that you would like to share regarding this student?
(e.g., Asthma or Breathing problems, Diabetes, Seizures, or other problem?) o Yes o No If yes (Specify)
Does the student have a health condition requiring possible emergency care? o Yes o No If yes (Specify)
Currently prescribed medications (Optional)
Is medication or a treatment (tube feeding or catheterization) being administered by school staff on a continuing basis, daily, or as needed?
o Yes o No
(If yes, MCPS Form 525-12, 525-13 OR MCPS Form 525-14 must be completed and returned to the school)
Printed Parent/Guardian Name
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute,
and are equivalent to my personal signature.
Signature of Parent/Guardian Date
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Student Emergency Information (Montgomery Schools)

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Completed 18 March 2021

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