FBISD Emergency Contact Form

Student's Name:*

First NameLast Name
Student ID:*
25-26 Campus:*
Date of Birth:*

MonthDayYear
Date
Gender:*
Student Age:*
24-25 Grade:*
Home Address:*
City:*
Zip:*
Home Phone #:*
Physician:*
Physician Phone #:*
Allergies:*

YesNo
List:*
Medications:*

YesNo
List:*
Medical Health Insurance Coverage:*

YesNo
Insurer:
Insurance Group #:
Insurance Member ID #:
Insurance Phone #:
Parent/Guardian #1 Name:*
Parent/Guardian #1 Cell Phone #:*
Parent/Guardian #1 Work Phone #:
Place of Employment:
Parent/Guardian #1 Email Address:
example@example.com
Parent/Guardian #2 Name:
Parent/Guardian #2 Cell Phone #:
Parent/Guardian #2 Work Phone #:
Place of Employment:
Parent/Guardian #2 Email Address:
example@example.com
Is your child currently under the care of a physician?*
If yes, please explain:
Does your child have any history of:*

Bleeding TendenciesHead InjuriesSeizuresAsthmaHigh Blood PressureTuberculosisSickle Cell AnemiaKidney Disease/InjuryKidney, Lung, or Eye Removed or Non-FunctioningHepatitisRheumatic FeverSkin DiseaseAllergyNeck InjuryBone or Joint InjuryHeart DiseaseDiabetesSurgical OperationAllergy to MedicationContact Lenses or GlassesNoneOther
Please explain Bleeding Tendencies:*
Please explain Head Injuries:*
Please explain Seizures:*
Please explain Asthma:*
Please explain High Blood Pressure:*
Please explain Tuberculosis:*
Please explain Sickle Cell Anemia:*
Please explain Kidney Disease/Injury:*
Please explain Kidney, Lung, or Eye Removed or Non-Functioning:*
Please explain Hepatitis:*
Please explain Rheumatic Fever:*
Please explain Skin Disease:*
Please explain Allergy:*
Please explain Neck Injury:*
Please explain Bone or Joint Injury:*
Please explain Heart Disease:*
Please explain Diabetes: *
Please explain Surgical Operation:*
Please explain Allergy to Medication:*
Please list any medications and/or illnesses that require medication not listed above:
Do you give permission for your child to receive Tylenol or Advil for minor aches/pains?*
Parent/Guardian Permit Waiver:

If, in the judgement of any representative of the schools, the said student should need immediate care and treatment as a result of an injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse, or school representative, and I do hereby agree to indemnify and save harmless the school and any school representative from any claim by any person whomever on account of such care and treatment of said student.
Parent Signature
Today's Date:*

MonthDayYear
Date
Should be Empty: