SANBORN REGIONAL SCHOOL DISTRICT EMERGENCY FORM
This form will accompany your child to the hospital in a medical emergency. Please read and complete all areas of this form.
Student's First Name *
Student's Last Name *
Student's Gender *
Student's Current Grade (For the 2020-2021 School Year) *
Student's Primary Street Address *
Student's Primary Town *
Mailing Address (if different from above)
What is your home phone number? *
Father's Work Phone
Student's Place of Birth *
Student's Date of Birth (mm/dd/yyyy) *
Mother's Full Name *
Mother's Cell Phone *
Mother's Work Phone
Mother's Email Address *
Father's Full Name *
Father's Cell Phone *
Father's Alt Phone
Father's Email Address *
Has either the student or a parent moved or changed a phone number in the past year? YES OR NO *
With Whom Does This Student Reside? *
Are there any special child custody provisions? If yes, please provide us with a copy of the legal document. *
SRSD Student Emergency Information Form
The information provided on this form will accompany your child to the hospital in a medical emergency. Please read and complete all areas of this form. Once submitted, you will receive a print-out of this information from the school which must be signed and returned to the main office.
Alternate #1: The name of a neighbor or relative who will assume temporary care of your student if you cannot be reached
Alternate #1: The address of the neighbor/relative
Alternate #1: The relationship the alternate #1 contact has to the student
Alternate #1: The cell phone of the alternate contact #1
Alternate #1: The home phone of the alternate contact #1
Alternate #2: The name of another neighbor or relative who will assume temporary care of your student if you cannot be reached
Alternate #2: The relationship the alternate #2 contact has to the student
Alternate #2: The address of the neighbor/relative
Alternate #2: The cell phone of the alternate contact #2
Alternate #2: The home phone of the alternate contact #2
Please use this space to list any routine daily medications the student takes (include name and dosage amounts)
Please use this space to list any known allergies (food, drug, environmental) the student has
Please use this space to describe any health conditions the student has
What is the student's physician's name? *
The city/town where the physician's office is located *
Physician's office phone number *
Dentist's office phone number
What is the student's dentist's name?
The city/town where the dentist's office is located
What is your hospital of choice for emergency transport? *
Has any of your information changed from last year? *
By printing your name in the box below, you recognize that the information on this form may be shared with school staff and emergency personnel as appropriate. It is the parent’s / guardian’s responsibility to share the students’s medical condition and treatment with transportation personnel (bus drivers). *
By printing your name in the box below, you recognize the following: In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated and follow his or her instructions. If it is impossible to contact the physician, the school may make whatever arrangements seem necessary. *
The health office will stock the following medications and will administer those checked off by a parent or guardian. These will be administered according to the package directions at the discretion of the school nurse. THIS FORM WILL BE IN EFFECT FOR THE CURRENT SCHOOL YEAR. Please place an “X” in front of those medications the school nurse may administer to your child.NOTE: If a parent / guardian requests administration of non-prescription medication not noted in the above list, the medication should be brought to the Health Office in the original container by a parent / guardian and a Hold Harmless form should be completed. *
Required
By printing my name below, I, the parent/guardian, authorize the school administrator to direct members of the school staff to assist my child in taking the above medication and agree that I will not hold liable, any member of the school staff or an individual of official capacity who is directed by me (parent / guardian) and the school administrator to assist my child in taking said medication. *
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