Detroit Community Schools Student Emergency Card
This information is strictly for the safety of your child.  We are not doctors and cannot perform medical procedures.  However, we need to know the correct action to take in the event your child becomes ill or injured.  If any of the following information changes please notify the front office immediately.  We will not release student to anyone whose name is not listed below.
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Student Information
Last Name *
First Name *
Middle Initial
Address *
Grade for Fall *
City *
State *
Zip Code *
D.O.B. *
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Gender *
Today's Date *
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Parent Contact Information
Name of Parent/Guardian *
Relationship *
Home Phone *
Cell Phone *
Work Phone *
Employer *
Employer Phone *
Email Address *
Name of Parent/Guardian *
Relationship *
Home Phone *
Cell Phone *
Work Phone *
Employer *
Employer Phone *
Email Address *
Emergency Contact Numbers (Required)
Person(s) to contact if parents are not available.  (List someone locally) Only those listed below will be allowed to sign out student (with valid ID)
Name *
Relationship *
Phone *
Name *
Relationship *
Phone *
Name *
Relationship *
Phone *
Family Doctor *
Office Phone *
Family Dentist *
Office Phone *
Ethnicity *
Please give a detailed explanation for any medical condition(s) concerning your child that the school should be aware of: *
Please indicate any type of allergy your child has: *
Give detailed instructions as to what procedure to follow in the event this child has an allergic reaction while in our care: *
Does your child have any unusual health conditions? *
If yes, please indicate: *
If your child have other unusual health conditions not listed above please give detailed explanation:
If emergency treatment is required and the parents or legal guardian cannot be reached immediately, your signature in the space provided below empowers the school authorities to exercise their own judgement in calling the physician indicated above or if not available to transport the child to the hospital emergency room.  Likewise, your signature below authorizes the release medical records pertinent to such an emergency room visit as the School District may request for its files.  This is a general authorization and is not sufficient for the release of confidential information protected by Federal Law.
Special Note:  At anytime where the above information is changed, these changes must be submitted to the principal or authorized school personnel in writing.
Signature of Parent/Guardian: *
Date *
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