Microsoft word - emergency care forms-shs.doc

JR. HIGH/HIGH SCHOOL
INFORMATION
Grade____________
Student Name______________________ Date of Birth ________ Place of Birth____________________ Ethnicity____________ (optional – used for grant writing purposes) Mother’s Name__________________________ Father’s Name_____________________________________ Mailing Address___________________________ Physical Address_________________________________________ Legal Guardian’s Name and Address if different from above________________________________________________ Home Phone #______________Cell #____________ Father Work #_______________ Mother Work #______________ Social Security Number______________ Number of schools student has attended including this one_______ Years of schooling Mother attended___________________ Years of schooling Father attended_____________________ Mothers occupation ____________________________________ Fathers occupation _______________________________________ This portion of the form is confidential and is for office use only. The bottom portion of this form will travel with your student on field trips and curricular/co-curricular events. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - EMERGENCY CARE / FIELD TRIP FORMS

SPECIAL HEALTH PROBLEMS/ ALLERGY/ MEDICATIONS:
GRADE___________
Please explain what the problem or allergy is, how you handle it, and what medication, if any, will be needed. Please list ANY
medications your child is currently on. If medication is needed, this form must be completed and returned to the high school office
prior to medication being given while at school. As per the Student Handbook, no medication is to be kept in your child’s
locker or school bag. All medication is to be kept locked up in the office at all times.

AUTHORIZATION FOR TREATMENT:
I hereby voluntarily consent to emergency treatment, first-aid screening, examinations, and minor treatment (such as antibiotic
ointment) as may be deemed necessary. I also voluntarily consent to preventative health screening including vision, hearing,
scoliosis, and other screenings as may be deemed necessary by the school nurse. I give my permission for the school nurse and/or
other designee to administer (according to protocol) the following over the counter medications: Acetaminophen (Tylenol),
Benedryl, Ibuprofen, cough drops and throat lozenges.
When unable to contact parent or alternative person, I hereby give my permission to the school to authorize any necessary emergency medical treatment deemed necessary, until the parent can be notified. YES____________ Guardian/Parent SIGNATURE_ ___________________Guardian/Parent (please print)___________________________ EMERGENCY PHONE NUMBERS______________, ___________________, _____________ ALTERNATIVE RESPONSIBLE PERSON__________________________________________ PHYSICIAN TO NOTIFY____________________________ Phone number ___________________________ My child has School Insurance_________Private Insurance___________No Insurance__________ Insurance information that I feel will be helpful in the event of an emergency: Primary ________________________________ ___________________________________ ________________________________ ___________________________________ ________________________________ ___________________________________ ________________________________ ___________________________________ CONSENT TO PARTICIPATE
I, as legal guardian/parent, give my permission for the above student to participate in all regularly scheduled field trips and extra-curricular/co-curricular outings during the 2006-2007 school year.

Source: http://www.superior.k12.mt.us/files/forms/23.pdf