EMERGENCY PROCEDURE FORM

WAPAKONETA HIGH SCHOOL

School Year 2005-2006

Date         /          /                                                                                                    Grade                              

 

Student’s Name                                                                                                                Birthdate ____/____/____

                                   Last                                                      First                                                         Middle

Address                                                                                                    Home Phone (______)______-_________

City                                                                                            Zip                                  Sex     M ______  F _____

Parent’s Email Address                                                   (home)                                                  (work)

 

 

MOTHER’S INFORMATION

Name                                                                      

Address                                                                  

City                                                                         

State                                          Zip                         

Home Phone (         )                                                

Employed By                                                           

Employer’s Phone (         )                                        

 

FATHER’S INFORMATION

Name                                                                      

Address                                                                  

City                                                                         

State                                                Zip                   

Home Phone (           )                                              

Employed By                                                           

Employer’s Phone (          )                                       

 

Child lives with (circle)         Both Parents                                    Mother Only                  Father Only                   Guardian

Mother/Stepfather                      Father/Stepmother         Step-parent’s name                                                       

If guardian, Name                                                                        Employer’s Phone (         )                                

 

Is there a court custody order pertaining to this student?               If so, who has custody?                                     

(Custody papers required)

 

Names and ages of ALL other children in the family:

NAME                                                                           Age                 Grade              Birth date                    

NAME                                                                           Age                 Grade              Birth date                    

NAME                                                                           Age                 Grade              Birth date                    

NAME                                                                           Age                 Grade              Birth date                    

 

**IMPORTANT – During the course of the school year there are times when a student may need to leave school due to illness or communicable disease requiring transportation home.  Parents or guardians may not be available during these times.  Students who are ill must be dismissed to a responsible adult.  Please list below the names of six adults (including yourself as parent/guardian) who you would prefer for us to call in case of an illness or emergency.  Please put these names in the order of whom you want called first, second, etc.  Please notify the school when telephone numbers change.

NAME                                                                      RELATIONSHIP                                                                                      PHONE NUMBER

1st                                                                                                                                                                                                                           

2nd                                                                                                                                                                                                                          

3rd                                                                                                                                                                                                                           

4th                                                                                                                                                                                                                           

5th                                                                                                                                                                                                                           

6th                                                                                                                                                                                                                           



 

                                                                                                                                                                                                                               

Student Signature                                                                                                    Parent/Guardian Signature

 

(IMPORTANT:  PLEASE SEE OTHER SIDE)

 

In order to help us plan for a safe and healthy school experience for your child, please check any of the following that currently apply to this student:

_____Asthma    If checked, please circle one of the following:                  `Mild                        Moderate                 Severe

_____Bleeding disorder (PLEASE EXPLAIN BELOW)

_____Diabetes

_____Epilepsy or Seizures (PLEASE EXPLAIN BELOW)

_____Has a cast, brace or other supportive or assistive device

_____Heart Condition (PLEASE EXPLAIN BELOW)

_____Life threatening allergies (anaphylaxis) (PLEASE EXPLAIN BELOW)

_____Medication during the school day (Required forms available in office.  Refer to district policy)

_____Pregnancy

_____Shunt

_____Wears a hearing aid

_____Wears corrective lenses (glasses or contacts)

_____Wears prosthesis

_____Central Line (Hickman, Groshong, etc) (PLEASE EXPLAIN BELOW)

         /         /          Date of last tetanus shot

**If there is further information to which we need to be made aware, please contact the school nurse at 419/739-5215.

 

The space below is provided for you to list any additional information concerning your child’s health or medical conditions of which the school staff should be aware.

________________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________

 

 

EMERGENCY MEDICAL AUTHORIZATION

 

*Note:  PART I OR PART II must be completed

 

            PART I:  TO GRANT CONSENT

 

I hereby give consent for the following medical care providers and local hospitals to be called:

 

DOCTOR                                                                                                 PHONE  (             )                             

DENTIST                                                                                                 PHONE  (             )                             

MEDICAL SPECIALIST                                                                            PHONE  (             )                             

LOCAL HOSPITAL                                                                                   PHONE  (             )                             

 

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent to (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my child to any hospital reasonably accessible.

 

This authorization does not cover any major surgery unless the medical opinions of two other licensed physicians or dentist, concurring for such surgery, are obtained prior to the performance of such surgery.

 

DATE             /           /          SIGNATURE OF PARENT/GUARDIAN                                                                                           

 

 

            PART II:  REFUSAL TO CONSENT

I do NOT give my consent for emergency treatment of my child.  In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

 

DATE             /           /          SIGNATURE OF PARENT/GUARDIAN