Emergency Card Information

Last Name *

First/Middle Name *

Student ID Number

D.O.B. *

Grade *

Ethnicity: Is the student of Hispanic, Latino or Spanish origin? *

Yes No

Race (Check appropriate race(s). *

White Black Asian Native American/Alaskan Native Hawaiian/Pacific Islander Multi-racial

Home Phone *

Best Phone# to contact *

Address *

City *

State *

Zip Code *

Parent/Guardian *

Employed By *

Work Phone *

Cell Phone *

E-mail Address *

example@example.com

Parent/Guardian

Employed By

Work Phone

Cell Phone

E-mail Address

example@example.com

Additional individuals who will care for child in case a parent/guardian cannot be reached: These individuals may sign my child out (Photo ID required)

Name *

Relationship *

Phone *

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

First and Last names of siblings attending Athenian Academy

Person(s) who MAY NOT legally contact or remove my child from school (Provide Legal Documentation)

It is the Parent/Guardian’s responsibility to keep the school updated with new information and contact numbers.

PARENT CONSENT
I hereby give my consent for my child, ________________________________, to participate in the School Health Services Program. This means that my child will receive vision, hearing, scoliosis, and blood pressure screening at certain grade levels. In addition, there is a health unit in 6^th, 7^th, and 8^th grade science on health issues such as abstinence, substance abuse prevention, dating and relationship issues, birth control, and sexually transmitted diseases at certain grade levels. If I object to any of these health screenings or programs, I will notify the school in writing. In case of accident or serious illness, I want to be contacted by the school. If the school is unable to reach me, I hereby authorize the school to contact the physician or dentist indicated below and to follow his/her instructions. If it is impossible to contact this physician or dentist, the school will take whatever actions are necessary to provide care and treatment for my child, and exchange medical information with the provider as necessary to support the continuity of care for my child. I agree to pay all expenses incurred by handling any emergency care. In case of an accident or illness where immediate treatment of my child is not indicated, but where he/she is unable to remain at school, I request that one of the person(s) listed above be contacted and requested to care for my child until I can be reached.

I give my consent for my child, blanks, to participate in the School Health Services Program described above. If I object to any of these health screenings or programs, I will notify the school in writing.

List of any medication(s) your child is currently taking

List any health problem(s) or allergies of which the school should be aware of

Does your child’s health problem(s) impact his/her learning ability?

YES No

If Yes, please explain

Physician's Name/Phone

Hospital Preference/Phone

Dentist's Name/Phone

If my child is covered by Medicaid and receives health services under IEP/TIEP, I consent for the school to bill Medicaid for those services.

Current Medicaid Card?

YES No

Medicaid Number

Parent/Guardian (Print) *

My signature indicates my parental consent, understanding, and agreement. *

Clear

Parent/Guardian (Signature)

Date *

Date

EMERGENCY INFORMATION CARD

Student Information

Parent/Guardian Information

Parent/Guardian Information