Student Health Emergency Form

Student Health Emergency Form

Student's Name                           

Grade Level:         Soc. Sec#   

Date of Birth (mm/dd/yyyy)  

Street Address

 

City         

 

Zip Code      

 

Primary Phone 

Parent of Guardian:  To serve your child in case of an injury or illness, it is necessary that we be furnished with the following information:

Mother's Name:      

Work Phone:            

Cell Phone:           

Mother's email  

     

Father's Name:

Work Phone:

Cell Phone:

Father's email  

Please list two friends or relatives who live near and will assume temporary care of your child if necessary:

Friend #1

Name:              

Relationship to Student: 

Primary Phone:        

Friend #2

Name:              

Relatioinship to Student:

Primary Phone:        

Please indicate by checking the over-the-counter medications you wish your child to receive in the event of pain or discomfort.  If you check the box then you are granting permission for EFISD to give your child these medications.

  Tylenol    Ibuprofen

Health Information:  Please list any allergies or chronic health conditions that may affect your child's academic and/or physical abilities:

 

I, the undersigned, do authorize officials of the Elysian Fields ISD to contact directly the persons named on this form, and do authorize the named physicians to render treatment as necessary. In the event physicians, parents, or persons named on the document cannot be contacted, the school officials are hereby authorized to take any action deemed necessary in their judgment for the health of the said student. In the event of injury or illness where transportation of the student is not available, I hereby authorize school officials to transport said student. I will not hold Elysian Fields ISD financial responsible for the emergency care and/or transportation of said student.

 

By Submitting this online document I affirm that I am the parent or guardian of the named student and that all information is correct and I am agreeing to its terms.

 

 

 



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