Registration

In case of Emergency

Emergency Contact Card
SCHOOL YEAR 20TO 20

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION(STUDENT RESIDES WITH):

Conditions requiring special consideration (Medical/Physical):

Does your student require:

(A) Epipen

   

YES

   

NO

       

(B) Inhaler

   

YES

   

NO

(C) ANY MEDICATION CURRENTLY TAKEN:(Type of medication and time of administration);

OTHER PARENT/GUARDIAN INFORMATION:

LIST BELOW NAMES OF THREE (3) PERSONS WHO MAY BE CALLED IN CASE OF EMERGENCY OR IF CHILD IS SICK AND YOU ARE NOT ABLE TO BE REACHED.

TO ANY DOCTOR OR HOSPITAL: In case | or any other contacts can not be reached in the case of an emergency, I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anestnesia, or surgery for my child as name above my, My signature below constitutes authorization to perform any necessary treatment for my child in an emergency.


HEALTH INSURANCE INFORMATION:

If there is a person who nay NOT HAVE ACCESS to child, please indicate:

Name

Relationship

order of protection Exists?

   

YES

   

NO