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Emergency Medical Information -Text Only-
5/23/2017
Emergency Medical Information -Text Only-
5/22/2017

 

Revised 02-24-12 vl 0

New Address or Phone Dixon Unified School District Date

 

STUDENT EMERGENCY / MEDICAL INFORMATION CARD

Name: Last First Middle Perm 113#

Grade: Home Room/Room: Birthdate: Age: Sex: ❑ Male ❑ Female

Home Address: Number Street Apt/Unit City Zip Code

Home Phone: Language Spoken at Home:

Parent/Guardian/Caregiver Name Parent/Guardian/Caregiver Name

Email Email

Home Phone Work Phone Home Phone Work Phone

Cell Phone Employer Cell Phone Employer

CHILD LIVES WITH: ❑ Mother ❑ Father ❑ Caregiver/Guardian ❑ Other (specify)

EMERGENCY CONTACTS (Not a Parent): In case child listed above becomes ill or is injured at school and a parent cannot be contacted, the school authorities have my permission to contact and release my child to the custody of one of the following (ID must be verified before child is released) :

Name Relationship Home Phone Cell Phone

 

To assure prompt attention to your child, PLEASE NOTIFY SCHOOL OF ANY CHANGES OF INFORMATION ON THIS CARD.

My child has health insurance ❑ Yes ❑ No

Provider Medical # Phone

My child receives regular care for the following medical condition(s):

  • NO MEDICAL CONDITION OR Medical Condition(s) Is/Are: ❑ Mild ❑ Life Threatening

  • Asthma I ❑ Seizures ❑ Diabetes Is Insulin Required? ❑ Yes ❑ No

  • Allergies/Allergic to: Date of last reaction: 1Requires Epinephrine: ❑ Yes ❑ No

Does your child have any other major health issue(s). Please list: Is your child taking any medication(s)? Please list medication(s) and times taken:

Medication: Times Taken:

Medication: Times Taken:

Medication: Times Taken:

Other children attending DUSD schools:

Name School Grade

If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for school authorities to take appropriate action for the safety and welfare of my child.

Parent's/Guardian's Signature