Microsoft word - emergencinformation.doc

COATESVILLE AREA SCHOOL DISTRICT ~ EMERGENCY INFORMATION
_____________________________________________________\_____\_____\_________________________________________ __________________________________________________________________________________________________________ Resides with: Mother ____ Father ____ Both ____ Guardian ____ Guardian’s Name: Mother’s Name ________________________________ Father’s Name ______________________________________ Place of Employment ______________________ Place of Employment ___________________________________ Work # ________________ Home # _________________Work # _________________Home # __________________ Email_____________________Cell # _________________
IF PARENT/GUARDIAN CANNOT BE REACHED, CONTACT:

1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________ MEDICAL HISTORY
Is your child allergic to bee/insect stings? No/ Yes Reaction and treatment: ______________________________________________ Is your child allergic to anything else? No/Yes What and treatment: ________________________________________________ Is your child taking any medication at home or school? No/Yes What/Why: ______________________________________________ Please list any history of medical conditions/concerns (asthma, diabetes, epilepsy, cardiac, ADD, etc.): ________________ ____________________________________________________________________________________________________________ Doctor ____________________Phone __________________ Dentist _________________Phone_________________ Does your child wear glasses? _____ Contact Lenses? _____ Hearing aides? _____ Other/Name_____________________ PLEASE COMPLETE BOTH SIDES OF THIS FORM!!!
Name/School of siblings attending Coatesville Area ________________________________________________________ ____________________________________________________________________________________________________________ Insurance Company ____________________________________________ Policy Number _______________________ I give my permission for my child to receive the following medications provided by the CASD and dispensed by the school nurse of the principal’s designee: Essence of Peppermint (for stomach aches) MEDICATION POLICY: If any medication must be sent to school, it must be in its original container accompanied by a signed note or school consent form from the parent or legal guardian. All medication must be dispensed in the Health Room according to the package directions or doctor’s note. This applies to both prescription and over the counter medications. If any medication sent to school is not in its original container, it will not be dispensed. Authorization for Emergency Services Treatment of Minor
I hereby give my permission for my child (name) _________________________________________________ to be treated at Brandywine Hospital for any emergencies. I also give my permission for the information on this card to be shared with appropriate school personnel. I hereby authorized the Coatesville Area School District to release to and obtain information from the family health care provider (immunizations, diagnoses, treatments). _______________________________________________

Source: http://www.coatesville.k12.pa.us/webs/sb/emergencinformation.pdf