Emergency Medical Form printable pdf download

Austintown Local School District

Emergency Medical (School Year 2015-16)

Student Information

For School Use Only:

Date of Birth:

Student Name:

Homeroom #____________

Gender:

Grade:

City/State:

Zip:

Address:

Parent/Guardian Information

Name:

#1 Contact Cell:

#2 Contact Home :

#2 Contact Home:

Relationship to Student:

Mother / Stepmother / Guardian / Foster Mother (please circle)

Father / Stepfather / Guardian / Foster Father (please circle)

Is your address the same as student’s? __ Yes __ No

(If No, what is your current address)?

Current Address/Zip:

Residential Parent / Guardian Information (please answer Ques. A, B, & C)

Are the student’s parents/guardians (please X one):

Student lives with (please X one):

__ Married __ Divorced __ Separated __ Never Married __ Otherwise

__ Both Parents __Mother Only __Father Only __Other: ___________

living separately, please explain:

_______________________________

If Separated or Divorced, Custody Papers are Required for

Who has legal custody for child(ren) (please X one):

Student File.

__ Both Parents __Mother Only __Father Only __Shared

__ Other: __________

For Joint-Custody, Please Provide Addresses of Both Parents.

Emergency/Alternate Contacts

In the event you are unable to reach me at the above numbers, you have my permission to contact the following alternates. They have my permission to receive health

care information regarding my child and can take them home during school hours if needed. ( Additional contact space provided on the back of form)

Contact 1 (Other than Parent/Guardian)

Contact 2 (Other than Parent/Guardian)

Name:

Relationship:

Best Contact Number:

Emergency Authorization

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by

named doctor below, or in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any

hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring

in the necessity for such surgery, are obtained prior to the performance of such surgery.

Consent given?

Yes (after reasonable attempts to contact parent/guardian)

PLEASE CIRCLE ONE

No (If no, please give instructions)

Consent Refusal Instructions:

Medical Contacts (if consent was given above, please enter contacts)

Doctor

Name:

Phone:

Dentist

Name:

Phone:

Hospital

Name:

Phone:

Branch ( if more than one location):

Medical Information (*Forms for each condition and medications administration forms are available from the school clinic) :

Please circle Yes or No

Will medication be

If yes, Name and

taken at school?

Dose

Inhaler: Yes or No

Asthma*:

Yes or No

Diabetes*:

Yes or No

Seizures*:

Explain:

Yes or No

Allergies*:

Yes or No

Explain:

Yes or No

Food Allergies*:

Explain:

Yes or No

Sting Allergies*:

Explain:

Yes or No

Heart Condition*:

Explain:

Yes or No

Other:

The Austintown Local School District Nurses (or other trained personnel) may administer acetaminophen (Tylenol) for pain during this school year,

to the students with signed parental permission? This applies to Grades 4-12 only.

Yes or No (please circle one)

The Austintown Local School District Nurses (or other trained personnel) may administer Benadryl for emergency reaction only, during this school

year, with signed parental permission?

Yes or No (please circle one)

BMI Screening (Body Mass Index screening for Grades Kg, 3

, 5

& 9

only). Part of Healthy Choices for Healthy Children Act.

PLEASE

Do you consent to have this screening done?

Yes or No (please circle one)

ANSWER

Grade student attend the boys’ or girls’ puberty education program presented by a district Registered Nurse?

May your 5

QUES. 1-4

Yes or No (please circle one)

AND SIGN

Date:

Signature:

Emergency Medical Form

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