2018-19 Emergency Care Form
This form is a copy of the emergency care card(from Augusta County Schools) required for all SVGS students. Please complete all questions. If the question is not applicable, please use NA to indicate so. Questions with a red asterick require some answer.
Thank you for your cooperation!
Student Last Name *
Your answer
Student First Name *
Your answer
Student Middle Name *
Your answer
Student Date of Birth *
(Month/ Day / Year)
Your answer
Gender *
Grade *
School *
Residence Address (Street) *
Your answer
Residence City *
Your answer
Mailing Address(Street) *
Your answer
Mailing Address(City) *
Your answer
Student Lives With (First & Last Name(s)) *
Your answer
Brothers/Sisters in School( First & Last Name(s)) *
Your answer
Student Phone # *
Your answer
Mother or Guardian *
Your answer
Mother Address(Street) *
Your answer
Mother Address(City) *
Your answer
Mother Employer *
Your answer
Mother Phone -Home *
Your answer
Mother Phone - Work *
Your answer
Mother Phone - Cell *
Your answer
Mother Email *
Your answer
Father or Guardian *
Your answer
Father Address(Street) *
Your answer
Father Address(City) *
Your answer
Father Employer *
Your answer
Father Phone -Home *
Your answer
Father Phone - Work *
Your answer
Father Phone - Cell *
Your answer
Father Email *
Your answer
Name *
Emergency Contact #1(if unable to reach parent/guardian)
Your answer
Phone *
Emergency Contact #1(if unable to reach parent/guardian)
Your answer
Relationship *
Emergency Contact #1(if unable to reach parent/guardian)
Name *
Emergency Contact #2(if unable to reach parent/guardian)
Your answer
Phone *
Emergency Contact #2(if unable to reach parent/guardian)
Your answer
Relationship *
Emergency Contact #2(if unable to reach parent/guardian)
Name *
Emergency Contact #3(if unable to reach parent/guardian)
Your answer
Phone *
Emergency Contact #3(if unable to reach parent/guardian)
Your answer
Relationship *
Emergency Contact #3(if unable to reach parent/guardian)
Student Doctor Name *
Your answer
Student Doctor Phone *
Your answer
Student Dentist Name *
Your answer
Student Dentist Phone *
Your answer
May we have permission to contact your child's doctor/dentist concerning his/her medical needs? *
Student Health Insurance *
Please indicate below any health problems your child has. development of a health care plan may be necessary to meet the needs of your child. For the safety of your child, this information may be shared confidentially with school employees unless you notify the school office in writing not to do so. *
Please check all that apply.
Required
Please list any other health problems of which we should be aware. If none, enter NA. *
Your answer
List any special health related treatment need at school. If none, enter NA. *
Your answer
Known Food Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Your answer
Known Insect Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Your answer
Known Medication Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Your answer
Known OTHER Allergies Requiring Medication: *
What substances AND what is the reaction? (If none, enter NA.)
Your answer
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.
Your answer
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.
Name of Parent/Guardian Completing this Form(This form must be completed by a parent/guardian.) *
First Name AND Last Name
Your answer
Date Form was completed *
Month/Day/Year
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service