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)
Level One – Includes low-cost generic and brand-name drugs. Level Two – Includes higher cost generic and brand-name drugs. Level Three – Includes high-cost, mostly brand-name drugs and some self-administered injectables. These drugs may have generic or brand-name alternatives in Levels One or Two. Level Four – Includes high technology drugs and self-administered injectable drug
THE SCHEDULE [see section 2(10)] In the Customs Act, 1969 (IV of 1969), in the First Schedule, for thecorresponding entries against “PCT Code”, "Description" and "CD%" specified incolumns (1), (2), (3) and (4) appearing in chapter 1 to 99, the following correspondingentries relating to “PCT Code”, "Description" and "CD%"- Chloramphenicol and its de