Colusa High School 20-21 Student Emergency Card Update
20-21
Student's Legal Name
*
First Name
Last Name
Student's Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the student's mailing address different than the home address?
*
Same as Home Address
Different than Home Address
Student's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household Primary Phone Number
-
Area Code
Phone Number
Student Email
example@example.com
Student Cell Phone
-
Area Code
Phone Number
Student Gender (Identified)
Female
Male
Non-binary
Student Gender (legal)
Female
Male
Non-binary
Student Birthdate
-
Month
-
Day
Year
Date
Student Grade Level
TK
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
School
James M. Burchfield
George T. Egling Middle
Colusa High School
Colusa Alternative High School
Colusa Alternative Home School
Will the student be riding the bus?
Yes
No
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Parent/Legal Guardian Information
Parent/Legal Guardian Information (REQUIRED - If you need to include more than two legal guardians, please contact the school.)
Check all that apply (copy of court documents are required)
Restraining Order
Restricted Custody Provisions
Court Order
Not Applicable
PARENT/LEGAL GUARDIAN #1
Parent/Legal Guardian #1 Full Name
*
First Name
Last Name
Parent/Legal Guardian #1 Email
example@example.com
Parent/Legal Guardian #1 Phone Number
*
-
Area Code
Phone Number
Parent/Legal Guardian #1 Work Number
-
Area Code
Phone Number
Extension
Parent/Legal Guardian #1 Employer Name
Parent/Legal Guardian #1 Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the Parent/Legal Guardian's mailing address different than home address?
*
Same as home address
Different than home address
Parent/Legal Guardian #1 Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Legal Guardian #1 Gender
*
Female
Male
Non-binary
Parent/Legal Guardian #1 Communication Preference (check all that apply)
Phone
Email
Text
Parent/Legal Guardian #1 Relationship to Student
Agency Representative
Aunt
Caregiver
Court Appointed Guar.
Father
Foster Father
Foster Mother
Grandfather
Grandmother
Mother
Other
Sibling
Stepfather
Stepmother
Uncle
PARENT/LEGAL GUARDIAN #2
Parent/Legal Guardian #2 Full Name
First Name
Last Name
Parent/Legal Guardian #2 Email
example@example.com
Parent/Legal Guardian #2 Phone Number
-
Area Code
Phone Number
Parent/Legal Guardian #2 Work Number
-
Area Code
Phone Number
Extension
Parent/Legal Guardian #2 Employer Name
Parent/Legal Guardian #2 Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the #2 Parent/Legal Guardian's mailing address different than home address?
Same as home address
Different than home address
Parent/Legal Guardian #2 Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Legal Guardian #2 Gender
Female
Male
Non-binary
Parent/Legal Guardian #2 Communication Preference (check all that apply)
Phone
Email
Text
Parent/Legal Guardian #2 Relationship to Student
Agency Representative
Aunt
Caregiver
Court Appointed Guar.
Father
Foster Father
Foster Mother
Grandfather
Grandmother
Mother
Other
Sibling
Stepfather
Stepmother
Uncle
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Emergency Contacts
Emergency Contact Information: Please list two Emergency Contacts, if you require more than two please contact your school office. Please notify the school if any of the individuals below require access to attendance, grades and discipline information.
Emergency Contact #1 Name
*
First Name
Last Name
Emergency Contact #1 Phone Number
*
-
Area Code
Phone Number
Emergency Contact #1Relationship to Student
*
Agency Representative
Aunt
Caregiver
Court Appointed Guar.
Father
Foster Father
Foster Mother
Grandfather
Grandmother
Mother
Other
Sibling
Stepfather
Stepmother
Uncle
Emergency Contact #2 Name
*
First Name
Last Name
Emergency Contact #2 Phone Number
*
-
Area Code
Phone Number
Emergency Contact #2 Relationship to Student
*
Agency Representative
Aunt
Caregiver
Court Appointed Guar.
Father
Foster Father
Foster Mother
Grandfather
Grandmother
Mother
Other
Sibling
Stepfather
Stepmother
Uncle
Sibling Information (Siblings Living in the Same Household as this Student):
Sibling #1 Name
Sibling #1 Birthdate
-
Month
-
Day
Year
Date
Sibling #1 Age
Sibling #1 Current School
Sibling #2 Name
Sibling #2 Birthdate
-
Month
-
Day
Year
Date
Sibling #2 Age
Sibling #2 Current School
Sibling #3 Name
Sibling #3 Birthdate
-
Month
-
Day
Year
Date
Sibling #3 Age
Sibling #3 Current School
Housing: Please indicate the current housing situation for this student
A fixed, regular adequate nighttime resident (permanent)
Temporarily living with another family due to economic hardship
Shelter or transitional housing
Hotel/Motel
Unsheltered (primary nighttime residence is not ordinarily used for sleeping accommodations- i.e. park, car, etc.)
Release of Information: Federal law required districts to release student directory information to the military unless parents notify the District that such information is not to be released (EC 49061 - 49076). Please indicate the appropriate box concerning the release of this information.
Yes, okay to release information
no, do no release information
Photo Release
No, I do not want pictures of my student displayed on district-controlled websites or publishing in newsletters.
Yes, I do want pictures of my student displayed on district-controlled websites or published in newsletters.
Local Field Trip Permission
Yes, I give my permission for my child to attend LOCAL (in town) field trips.
No, I do not give my permission for my child to attend LOCAL (in town) field trips.
Student Emergency & Health Information
In the event of an accident, or other emergency, when a parent or guardian is unavailable, a representative of the school will make arrangements as he / she considers necessary for the child to receive medical hospital care, including necessary transportation, in accordance with their best judgement. Such care and treatment will be performed by a licensed health professional.
Health Insurance Provider
Insurance ID #
Hospital Preference
*
Does your son / daughter have any condition, which may result in an emergency?
*
Yes
No
If yes, please explain the condition
Does your child have a physical condition which limits participation in Classroom Activity?
*
Yes
No
Please explain the physical condition
Does your child have a physical condition which limits participation in Physical Education?
*
Yes
No
Please explain the physical condition
Has your child been in contact with anyone known to have tuberculosis?
*
Yes
No
If yes, when?
If yes, was skin test:
If Positive, was a chest x-ray done?
If yes, when / where
Past illness (check all the apply). Please check any of the following symptoms, which have been noted recently.
Measles (Rubella - 10 Day)
Measles ( 3 day)
Rheumatic Fever
Chickenpox
Scarlet Fever
Whooping Cough
Mumps
Diphtheria
4 or More Colds Per Year
Frequent Sore Throats
Frequent Headaches
Frequent Leg or Joint Pain
Speech Difficulty
Dizziness
Fainting Spells
Abdominal Pain
Frequent Urination
Persistent Cough
Ear Infections
Frequent Nose Bleeds
Night Sweats
Tires Easily
Shortness of Breath
None
Vision History
Known eye condition (other than corrective lenses)
Wears Glasses
None
Date of last exam
-
Month
-
Day
Year
Date
Hearing History
No Hearing Issues
Permanent Hearing Loss
Frequent Infections
Hearing Aid
Date of last exam
-
Month
-
Day
Year
Date
Medication/Health Conditions
A current signed PHYSICIAN AUTHORIZATION FOR MEDICATION IN SCHOOL form must be on file in the office for any student taking medications (prescribed by a physician or over the counter, during school hours). THIS FORM MUST BE RENEWED YEARLY.
Does medication need to be administered during school hours?
*
Yes
No
Student has the following conditions
*
Asthma
Type II Diabetes
ADHD / ADD
Taking Medication for Other Condition
Orthopedic Conditions
Hospitalization
Type I Diabetes
Heart Condition
Seizure Disorder
Severe Allergic Reactions
Other Physical Limitation
None
Requires Medication?
*
Yes
No
Asthma Medication
Daily
As Needed
With Exercise
Administer during school hours
N/A
Diabetes Medication
Oral
Pump
Injected
Administer during school hours
N/A
Heart Condition
Physical Restriction
Requires Medication During School Hours
None
Heart Condition Diagnosis:
ADHD/ADD Medication Administered During School Hours?
Yes
No
N/A
Seizure Medication to be administered during School Hours?
Yes
No
N/A
Date of Last Seizure:
-
Month
-
Day
Year
Date
Does your student have any of the following conditions?
*
Allergies (Seasonal)
Behavioral Problems
Bladder Problems
Bleeding Problems
Bowel Problems
Cerebral Palsy
Cystic Fibrosis
Dental Problems
Developmental Problems
Emotional Problems
Head Injury/Concussion
Migraine Headaches
Muscle Problems
Speech Problems
Spinal Injuries
Surgery
None
Student Allergies:
Severe Allergic Reactions:
Breathing Difficulties
Hives
Severe Allergic Reactions Medication:
Epi-Pen
Severe Allergic Reactions Medication
List Orthopedic or Physical Limitations:
Equipment or Care used for Orthopedic / Physical Limitations:
Please explain any conditions from above.
Parent/Guardian Signature
*
Clear
Parent/Guardian Name
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
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