Charlotte-Mecklenburg Schools HEALTH SURVEY AND EMERGENCY LOCATION CARD
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Email *
Student’s Last Name                                                   *
Student’s First Name                                                   *
Student’s Middle Name                                                  
Date of Birth: *
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Student Grade *
Student ID Number *
Student Bus #
Student’s Home Address                                                                                                                                           *
Zip Code *
Father/Guardian Name                                                                    
Work Phone #                                              
Cell Phone #
Mother/Guardian Name                                                                    
Work Phone #                                              
Cell Phone #
IN CASE OF ILLNESS OR EMERGENCY, THE FOLLOWING PERSONS MAY BE CONTACTED IF THE PARENTS/GUARDIAN CANNOT BE LOCATED:
Name of Friend/Neighbor/Relative                                                                             *
Phone #/Cell #   *
Name of Friend/Neighbor/Relative                                                                             *
Phone #/Cell #   *
Name of Doctor/Phone #                                                                                         *
Name of Dentist/Phone #                                                                          
In the event my child is involved in an accident or become sick to the extent that he/she should remain at school, I understand that the parent/guardian will be notified immediately.  If they cannot be contacted, the neighbor/friend/relative listed on this card will be contacted. If the accident or illness is not an emergency nature, the child will remain at school until arrangements can be made for his/her care.  However, in the event the accident or illness seems so severe that any delay in contacting a parent prior to seeking medical help will be dangerous to the child, or in the event the child needs immediate medical attention and the parents cannot be contacted, the school principal (or a responsible person representing the principal in the absence of the principal) has my permission to take the child to a doctor or clinic with the understanding that I will bear the financial responsibility for transportation and treatment.
Type your name here to sign. *
Date: *
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Student’s who have certain physical, emotional, mental, or behavior conditions may qualify for special services or require special considerations;PLEASE indicate whether any of the following or other conditions exists:
If you selected other, please explain.
Does your child have any Life Threatening Allergies/Reactions? (If to food, medication, insects, please list)
Has your child had any hospital visits in the last 12 months? (If so, for what?)
Describe special needs of the student that result from physical, emotional, mental, or behavior conditions:
Special Diet:
Insurance Provider
Insurance Number
Medicaid Number
REGARDING MEDICATIONS AT SCHOOL: It is necessary for us to regard all medications as if they were prescription, even Tylenol/Aspirin.  A medication authorization form must be completed by the doctor and parent in order for any medication to given at school.  This authorization form may be obtained at your student’s school. NOTE:  The school nurse can be contacted through the office, when additional information needs to be provided or consultationist needed during the school year.
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