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2021-22 Emergency Care Form
This form is a copy of the emergency care card required for all SVGS students.  If the question is not applicable, please use NA to indicate so.  Information with a red asterisk attached are required.  Thank you for your cooperation!
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Student Last Name *
Student First Name *
Student Middle Name *
Student Date of Birth *
(Month/ Day / Year)
Grade *
School *
Residence Address (Street) *
Residence City *
Mailing Address(Street) *
Mailing Address(City) *
Student Lives With (First & Last Name(s)) *
Student Phone # *
Parent/Guardian 1 *
Parent/Guardian 1 Address(Street) *
Parent/Guardian 1 Address(City) *
Parent/Guardian 1 Employer
Parent/Guardian 1 Phone -Home *
Parent/Guardian 1 Phone - Work
Parent/Guardian 1 Phone - Cell *
Parent/Guardian 1 Email *
Parent/Guardian 2 *
Parent/Guardian 2 Address(Street) *
Parent/Guardian 2 Address(City) *
Parent/Guardian 2 Employer *
Parent/Guardian 2 Phone -Home *
Parent/Guardian 2 Phone - Work
Parent/Guardian 2 Phone - Cell *
Parent/Guardian 2 Email *
Name *
Emergency Contact #1(if unable to reach parent/guardian)
Phone *
Emergency Contact #1(if unable to reach parent/guardian)
Relationship *
Emergency Contact #1(if unable to reach parent/guardian)
Name *
Emergency Contact #2(if unable to reach parent/guardian)
Phone *
Emergency Contact #2(if unable to reach parent/guardian)
Relationship *
Emergency Contact #2(if unable to reach parent/guardian)
Name *
Emergency Contact #3(if unable to reach parent/guardian)
Phone *
Emergency Contact #3(if unable to reach parent/guardian)
Relationship *
Emergency Contact #3(if unable to reach parent/guardian)
Student Doctor Name *
Student Doctor Phone *
Please list any other health problems of which we should be aware.  If none, enter NA. *
List any special health related treatment need at school.  If none, enter NA. *
Known Food Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Known Insect Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Known Medication Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Known OTHER Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
All medications taken:
Enter the name of the medication, what it is used for AND whether it is taken at home or school(If none, enter NA.).      You must supply any needed medication for your child.  Student must have written physician and parent/guardian permission for medications given at school.
The school has my permission in an emergency to contact my child's physician, call the rescue squad or take my child to the nearest hospital emergency department and the hospital staff has my authorization to provide treatment which is deemed necessary for the well being of my child.  I agree to pay the cost and expenses incurred. *
I give permission for my child to receive blood or blood products at the hospital in an emergency. *
My student has an IEP (Individualized Education Plan), 504 Plan, or Health Care Plan.
Clear selection
Name of Parent/Guardian Completing this Form(This form must be completed by a parent/guardian.) *
First Name AND Last Name
Date Form was completed *
Month/Day/Year
Submit
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