Emergency information form 2007-2008

EMERGENCY INFORMATION FORM - 2012-2013
BIRMINGHAM PUBLIC SCHOOLS
BIRMINGHAM COVINGTON SCHOOL
Residing in home with Student: Mother Father Step-Parent Guardian (Check all that apply) PLEASE READ THESE DIRECTIONS CAREFULLY BEFORE COMPLETING THE REMAINDER OF THIS FORM.
♦ Number the Emergency Call Order # boxes in the order parents/guardians and emergency contacts are to be called.
♦ Circle the preferred telephone number to call in case of emergency.
♦ Check the Authorized Treatment box to indicate the person(s) with legal authority to consent to medical treatment.
♦ Check the Authorized Pick Up box to indicate the person(s) having permission to pick up your child from school.
PARENT/GUARDIAN INFORMATION
1 Parent/Guardian Name Male/Female (circle one)

Emergency
2 Parent/Guardian Name Male/Female (circle one)
EMERGENCY CONTACTS OTHER THAN PARENTS/ GUARDIANS (including step-parents)

Emergency

Emergency

Emergency

Emergency
I acknowledge the information on this form is true and accurate.
I am responsible to notify the appropriate school personnel when this information changes.

Parent Signature_____________________________________________________________ Date ____________________________________________
HEALTH INFORMATION Birmingham Covington School
Student Last Name
First Name
DOES YOUR CHILD HAVE ANY SPECIFIC PHYSICAL/HEALTH PROBLEMS?

CHECK ANY OF THE FOLLOWING MEDICAL CONDITIONS YOUR STUDENT HAS.
Diabetes
Psychological
Other: (Be Specific)
Convulsive
Neurological
Orthopedic
Other: (Be Specific)
Abnormalities
Disorder, Seizures

LIST ANY MEDICATION(S) THE STUDENT IS ALLERGIC TO: (Be Specific)
LIST ANY OTHER ALLERGIES THE STUDENT MAY HAVE – BE VERY SPECIFIC WHEN LISTING

Food (e.g.) peanuts
Products (e.g. Latex)
Other (e.g. molds, dust)

LIST PHYSICIANS (S) OR SPECIALIST(S) PROVIDING CARE TO ANY OF THE ABOVE MEDICAL OR
ALLERGY CONDITIONS
Condition:

LIST ANY MEDICATION(S) THE STUDENT IS TAKING AND THE REASON FOR THE MEDICATION
PERMISSION TO ADMINISTER MEDICATION FORMS ARE REQUIRED FOR ANY OF THE FOLLOWING MEDICATIONS
ADMINISTERED AT SCHOOL (forms are available in Attendance Office). Please check those medications that will be administered at school.

Benadryl
Peak Flow Meter
Prescription or Over the Counter Medication
Blood Sugar Test
Asthma Inhaler
Prescription or Over the Counter Medication

STUDENT’S PRIMARY PHYSICIAN: ___________________________________________ Phone Number ____________________

Address ________________________________________________________ City & Zip ___________________________
HEALTH INSURANCE COMPANY ________________________________________Policy Number ____________________________
IN CASE OF EMERGENCY the school authorities have my permission to take such action as they deem necessary. ______________________________
Emergency personnel have the legal right to “save life or limb” so no child’s life is in danger when a parent cannot be contacted. However, some emergency personnel, including physicians and hospitals, wait until a parent is present before initiating treatment. Some hospitals may be willing to proceed in the absence of a parent if a WITNESSED SIGNATURE is available. Please read and check ONE of the following statements.
(Witnessed signature required.)

__ ______In case of an injury or illness involving my son/daughter, ___________________________, and when neither parent/guardian can be
r
eached at the phone numbers provided, WE AUTHORIZE emergency personnel, as well as the attending physician and hospital personnel to
ake such action and give such treatment as they deem advisable for our child’s comfort and well-being. __ ______In case of an injury or illness involving my son/daughter, ___________________________, and when neither parent/guardian can be eached at the phone numbers provided, we DO NOT give our consent for any medical treatment, including where illness or injury may require
mergency treatment. We direct the District authorities, emergency personnel and any medical professional, hospital or medical facility to take no action whatsoever until we have been contacted. NOTE TO PARENTS/GUARDIANS: This provision shall not apply to an emergency in
w
hich the child’s life is in danger.
_____________________________________________ _________ _________________________________________________ ________ P arent/Guardian Signature Date Witness Signature (Required)

Source: http://www.bcsonline.info/Documents/Registration/7_Emergency_&%20Health_%20Information_form.pdf