Bristol Township School District Confidential Student Emergency Card 2011 -2012

BRISTOL TOWNSHIP SCHOOL DISTRICT CONFIDENTIAL STUDENT EMERGENCY CARD 2014 - 2015

Student Name: ______likes to be called: ______Sex: M or F

m (Last) (First)

Date of Birth: ______Language spoken at Home: ______Grade: ______Homeroom: ______

Student’s Home Address: ______

Phone (home): ______Email : ______Student Lives With:______

Father’s Name: ______

Address: ______

Phone (home):______Cell Phone: ______Work Phone: ______Email______

Mother’s Name: ______

Address: ______

Phone (home):______Cell Phone: ______Work Phone: ______Email______s

Step Parent/Guardian’s Name______

Phone (home):______Cell Phone: ______Work Phone: ______Email______

Family Physician: ______Office Phone: ______Office Fax #: ______

Medical Specialist (if any): ______Office Phone: ______Office Fax #: ______

May we contact the sources listed above if needed? _____Yes _____No _

r Local person to be called in case of accident or serious illness other than parent/guardian: (please note that parents/guardians will be called first and then a

d those listed below in chronological order) e

Name Address Phone Relationship _

1. ______

2. ______

1. Does the student wear glasses or contacts? Dental braces? Dental appliance? Hearing aids? Right Left Both Circle all that apply. R

/ 2. Does the student have known allergies to medications, latex, foods, and environment? List: C

______s

3. Does the student need to use an inhaler? (Name of inhaler and frequency)______4. Does the student need an Epi-Pen? ______

5. Does the student have any medical diagnosis or mental health problems? ______

6. Are there any problems that may interfere with the student’s academic progress or require nursing attention during the school day? ___Yes __No _

Explain any of the above: ______

_ (Please complete the other side and remember to include your signature)

7. Is your child taking any medication on a regular basis? _____ Yes _____No if yes, please list the medication, time and dosage:

Name of Medication Time Taken Dosage Reason takes medication

1. ______

2. ______3. ______

May we share this information with your child’s teachers/appropriate staff? _____Yes _____No Please be aware that all information is considered CONFIDENTIAL.

The state of Pennsylvania mandates physical exams for students in the following grades: K or 1, 6 and 9 and dental exams for students in grades K or 1, 3 and 7. Please indicate if you want the school exam for your child or if you will provide written proof of your own provider’s exam. (This information must be on file in the health office by September 30 th of each school year. If not received by then, your child will be scheduled for an exam by the school provider.) ______I wish the school to provide a physical exam. Immunizations are not a part of this exam. ______I will provide written documentation of my own provider’s physical exam & immunizations. ______I wish the school to provide a dental exam. ______I will provide written documentation of my own dental provider’s exam.

Please be aware that the state also mandates height/weight including Body Mass Index, vision, hearing and scoliosis screenings in age appropriate grades. Your school nurse will contact you with any findings that may require private follow-up.

The following medications are available in the health office if your child experiences pain, fever, diarrhea, or a mild allergic reaction during the school day. Please indicate if the health room staff may give the following to your child:

Acetaminophen (generic Tylenol) yes no Tums yes no Imodium (secondary only) yes no Ibuprofen (generic Advil/Motrin) yes no Benadryl yes no Emetrol or generic anti-nausea yes no Hydrocortisone Cream yes no Bacitracin Topical Antibotic yes no

Does your child have current medical insurance? Yes No Insurance Company: ______Does your child have current dental insurance? Yes No Insurance Company: ______Does your child have current vision insurance? Yes No Insurance Company: ______

I understand that in the event of an emergency, my child may be transported via ambulance and treated at a local Emergency Department if necessary, I understand I don’t understand and that any expenses incurred will be my responsibility. (circle one)

Parent / Legal Guardian Signature______Date______

Please note that all prescription and over the counter medications (except those OTCs you have circled above) will only be administered during the school day if they are in a properly labeled container with signed physician/dentist order AND written parent consent. Health services personnel do not accompany students on field trips. Please discuss arrangements for daily medications with your Certified School Nurse at least one week prior to any field trip the student may take.