STUDENT
EMERGENCY AUTHORIZATION FORM
Student Name: DOB:
/ / School: MW MOH MS HS Grade:
Address: Town:
Zip: Home Phone:
Student resides with*: Name(s) Relationship:
Father’s Name: Mother’s
Name: Guardian’s
Name:
Cell phone: Cell
phone: Cell
phone:
Employed at Employed
at Employed
at
Work phone: Work
phone: Work
phone:
1st e-mail: 1st
e-mail: 1st
e-mail:
Alternate “: Alternate
“: Alternate
“:
*If student does not reside with both
parents, a court decree or legal agreement establishing custody must be on file
at school for child to enter/continue school.
IN CASE OF EMERGENCY OR ILLNESS
If parent/guardian is
not available, contact:
Name: Address:
Town:
Phone:
Family physician: Address: Town:
Phone:
Family dentist: Address:
Town:
Phone:
Family Insurance (agency & address): Certificate
number:
School Insurance (check one): Yes, Plan 1/24 hr Yes, Plan 2/schooltime No plan
MEDICAL INFORMATION
a) Acetaminophen
(Tylenol) may be given? Yes No b) Student wears glasses? Yes No
Antacids
(Tums) may be given? Yes No Student wears
contact lenses? Yes No
Ibuprofen
may be given? Yes No
Topical
creams may be applied? Yes No (i.e. Bacitracin, Bactine, 1% Hydrocordisone,
Caladryl, Anbesol, Blistex)
c) Allergies? Yes No If yes, please specify:
d) Asthma? Yes No If yes, does your child use an inhaler? Yes No
e) Date of
most recent DPT (Diphtherial/Tetanus) Immunization Booster: / /
f) Medication(s)
taken regularly; please specify:
g) Significant
health issues or surgeries in the past year?
Specify:
h) History of
head injury, other medical condition(s)?
Specify:
CERTIFICATION AUTHORIZATION
I/we understand that the school cannot guarantee the
safety of students, but rather In
case of medical emergency, in the event
that it is the school’s obligation to take due care
and exercise reasonable precautions that
I/we cannot be reached, I/we authorize
for the safety and well-being of
students. My/our child also has responsibility the
for his/her safety and the safety of
others. I/we understand that the school district employees, and other officers to procure
does not have insurance coverage for
student accidents and that the school relies and
consent to any medical examination,
on the parents/guardians of children
to carry either accident or health insurance to diagnostic
process or course of treatment,
protect them from medical costs
arising from accidental injury. I/we state that I/we including transportation and hospital
care,
are residents of the
that the information provided on this
form is true and complete; that I/we will the
supervision of any duly licensed health
immediately advise the school of any
changes to the above; and that I/we understand care
provider. A copy of this authorization
that the school will rely upon the
information on this form in all matters and actions is to be accepted as valid as the
original.
involving my/our child.
Parents’/Guardians’ _________________________________ _______________________________
signatures
needed Name Date Name Date
under both
columns.
_________________________________ _______________________________
Name Date Name Date
NOTE TO PARENT/GUARDIAN: It is important that the parent/legal guardian notify the
principal and
school
nurse immediately of any modifications to the above information.
Complete,
print out, sign and return form within seven days to your child’s school.