Fillable Valleynowpacketrusd Rialto Unified School District (San Bernardino Valley College)

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Valleynowpacketrusd Rialto Unified School District (San Bernardino Valley College)

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San Bernardino Valley College
San Bernardino Valley College
Confidential Youth Emergency Card
Summer
Fall
Spring 20____
Student Last Name
Student First Name
Student Date of Birth
SBVC ID#
Home Phone
City
State
Zip Code
Father’s/Guardian’s Name
Home Phone#
Work Phone #
Cell Phone #
Mother’s/Guardian’s Name
Home Phone#
Work Phone #
Cell Phone #
A local person in case of illness or injury if parent/guardian cannot be reached:
Name
Relationship
Cell Phone #
Physician’s Name
Phone #
Medical Insurance:
Subscriber #
Please list any medical conditions we should know about in an emergency:
Are there medications the students takes regularly: No Yes
Please
List:
Does the student have any allergies to medications or other substances:
No
Yes
Please List:
Students seeking emergency
care, birth control, pregnancy
testing, or STD/HIV screening
and care are considered by law
to be mature minors with the
right to consent for these
specific medical services.
I, the undersigned parent/guardian of __________________________________________, hereby authorize the
Medical and counseling staff of San Bernardino Valley College (SBVC) Student Health, as agent of the undersigned to
consent to any diagnostic procedure (including x-rays), to the administration of any counseling, medical, surgical
treatment, or to any accredited hospital when any or all of the foregoing is deemed advisable and is to be rendered
under the general Supervision of any Physician or surgeon licensed under the provisions of the Medical Practice Act.
I DO DO NOT grant the staff of the SBVC student health permission to give the above named student over the
counter medication for symptom relief if they are unable to reach me for verbal consent.
This authorization is given in advance of any specific diagnosis, treatment, or medical care being required and pursuant
to the provisions of Section 25.9 of the California Civil Code.
It shall remain in effect throughout the term designated on this form.
Parent Signature
Date
San Bernardino Valley College
Tarjeta de emergencia confidencial de menores
Padre o tutor legal, sírvase escribir en letra de molde y tinta la información solicitada abajo:
Apellido: ____________________________________ nombre: ____________________________________
Fec. nac.: __________________________________ núm. de identificación estudiantil de SBVC: _________
Teléfono de casa: ___________________________ domicilio: _____________________________________
Ciudad: _____________________________________________ código postal: _______________________
_____________________________ ________________ ________________ _______________
Nombre del padre/tutor legal núm. telefónico núm. de trabajo núm. de celular
_____________________________ _______________ _______________ _______________
Nombre de la madre/tutora legal núm. telefónico núm. de trabajo núm. de celular
Una persona de contacto local en caso de enfermedad o lesión si no se pueden comunicar con el
padre/tutor legal:
Nombre: ______________________________ parentesco: _________________ teléfono: ______________
Nombre del médico: ____________________ teléfono: _________________
Seguro médico: _____________________ núm. del suscriptor: ___________
Sírvase apuntar cualquier condición médica que debamos saber en una
emergencia.
_____________________________________________________________
¿Está el alumno tomando algún medicamento con regularidad? no sí
Sírvase apuntarlas: _____________________________________________
¿Tiene el alumno alguna alergia a medicamentos u otras sustancias?
Sírvase apuntarlas: _____________________________________________
Los alumnos buscando
atención de emergencia,
método anticonceptivo,
pruebas de embarazo o
atención y revisión de ETS/VIH
se consideran por ley ser
menores con madurez con el
derecho a consentir para estos
servicios médicos específicos.
Yo, el padre/tutor legal suscrito de ____________________________________, por el presente autorizo al personal
médico y de asesoramiento de San Bernardino Valley College (SBVC) Student Health, como agente del suscrito para
consentir a cualquier procedimiento diagnostico (incluyendo rayos-x), a la administración de cualquier tratamiento
quirúrgico, médico o de asesoramiento o a cualquier hospital acreditado cuando todo o cualquiera de lo antedicho se
considere aconsejable y que ha de prestarse bajo la supervisión general de cualquier médico o cirujano licenciados bajo
las estipulaciones de la Ley de Práctica Médica.
Yo NO SÍ otorgo al personal de SBVC Student Health permiso para dar al alumno antes nombrado medicamento sin
receta para aliviar síntomas si no se pueden comunicar conmigo para el consentimiento verbal.
Esta autorización se da por adelantado de cualquier atención médica, tratamiento o diagnostico específicos que se
requieren y están en cumplimiento con las estipulaciones del Artículo 25.9 del Código Civil de California.
Seguirá vigente hasta el plazo designado en este formulario.
X_______________________________________________________ fecha: ______________________
SU
FA
SP 20 __
Firma del Padre
Admissions and Records
RELEASE OF INFORMATION FORM
701 S Mt. Vernon Ave. San Bernardino, CA 92410 www.valleycollege.edu
PROXY TRANSACTIONS AND IDENTIFICATION REQUIREMENTS
Picture identification is required for ALL transactions at the San Bernardino Valley College Admissions and
Records Office. Anytime a student is unable to initiate a transaction, an appointed person may be authorized to
complete the transaction for the student by completing this form. With the exception of RUSH service for Transcripts
and Enrollment Verifications, a receipt of the completed transaction will be mailed directly to the student. (Revised:
01/11/14)
In order to protect the privacy of student records (Ed Code 76243) and FERPA (Family Education Rights and
Privacy Act) of 1974, the following information is required for all proxy transactions:
(PLEASE PRINT)
Student’s Name
Last First M.I.
Mailing Address
Number Street City State Zip Code
Student’s SBVC ID# Date of Birth
Name of Appointed Person
Last First M.I.
Relationship to Student
Student Signature
Date
Or
Notary Public
State of County of
On this, the day of, 20 before me a notary public, the undersigned officer, personally appeared, known to me
(or satisfactorily proven) to be the person whose name is subscribed to the instrument within, and acknowledged that the
person executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
Notary Public signature
Official Use Only
A&R Staff Date Academic Year
No faxed, emailed or copies submitted by anyone other than student will be accepted
High School District
Description of transaction to be completed: (For Example: Order transcripts, Submit high school paperwork, Pay
Fees, etc.)
Release attendance information, student information (name, email, SBVC ID, phone number), enrollment status, registration holds,
course progress, and transcripts.
Rialto Unified School District
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Valleynowpacketrusd Rialto Unified School District (San Bernardino Valley College)

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Completed 25 July 2020

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