• Student Emergency Card

    In case of an emergency, it is imperative that the school is able to reach a student’s parent/guardian. This information will be shared with the school nurse and administration on a need to know basis, and with emergency medical staff in the case of an emergency, unless you notify us otherwise.
  • Student Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Student Health History Update

    This information will be shared with the school nurse and administration on a need to know basis, and with emergency medical staff in the case of an emergency, unless you notify us otherwise.
  • 1. Please check if your child has had difficulty with any of the following. Please provide updates and additional information in the comments section. *An Asthma Action Plan, Food Allergy Action Plan, or Seizure Action Plan is required for all students with asthma or seizures
  • 2. Does your child have allergies to medicine, latex, insect bites or other allergies?*
  • 3. Does your child have a food allergy diagnosed by a licensed health care provider?*

  • If yes, a food allergy action plan completed by a licensed healthcare provider is required.

  • Student Health History Update

    This information will be shared with the school nurse and administration on a need to know basis, and with emergency medical staff in the case of an emergency, unless you notify us otherwise.
  • 4. Has your child seen a healthcare provider since school ended in June?*
  • 5. Is your child being treated or evaluated for any health conditions?*
  • 6. Is your child on any medication or treatment?*
  • Does your child need medication during school hours?
  • 7. Has your child been prescribed glasses or contact lenses?*
  • 8. Has your child had any major life events, such as recent move, death, separation, divorce, etc. since the end of the last school year? If yes, contact your school nurse or school counselor.*

  • Medical Information & Medicine Permission

    This information will be shared with the school nurse and administration on a need to know basis, and with emergency medical staff in the case of an emergency, unless you notify us otherwise.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • I give permission for my child to have Acetaminophen (Tylenol®) as determined by the nurse.*
  • I give permission for my child to have Ibuprofen (Advil®) as determined by the nurse.*
  • I give permission for my child to have First Aid Cream.*
  • I give permission for my child to have Caladryl®*
  • I give permission for my child to have Tums®*

  • School Emergency Procedures

  • Your schools have adopted the following procedures that will normally be followed in caring for your child when they become sick or injured at school. In extreme emergencies the school will seek immediate medical care. In case of emergency and/or need of medical or hospital care:

    1. The school will call home. If there is no answer, the school will call parent/guardian #1 or parent/guardians #2 place of employment.
      If there is no answer, the school will call the other telephone number(s) listed and the physician.
    2. If none of the above answer, the school will call the ambulance, and if necessary, transport the student to a local medical facility.
    3. Based upon the medial judgement of the attending physician, the student may be admitted to a local media facility.
    4. The school will continue to call the parents/guardians or physician until one is reached.
    5. The information on this form may be shared with emergency medical staff.

    If I cannot be reached and the school authorities have followed the procedures described, I agree to assume all expenses for moving and medically treating this student I also hereby consent to any treatment, surgery, diagnostic procedures or the administration of anesthesia, which may be carried out based on the medical judgement of the attending physician.

  • Emergency Contact Information

    Important: Must be 18 years of age or older. In the event of an emergency, individuals listed here will be contacted if parent/guardian cannot be reached.
    • Emergency Contact #1 Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Emergency Contact #2 Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: