emergency information

Brothers/Sisters
Please check box/boxes to indicate who has legal custody: Please furnish court documents to the school principal.
Address Cell Phone # ___________Pick up rights?___ Cell Phone # ___________Pick up rights?___ Cell Phone # ___________Pick up rights?___ Has either parent had parental rights revoked? ___ Yes ___ No Which Parent? ______________ Document # __________________ Father’s Work Relationship to Student______________________________________ Is English the primary language spoken in the home? ___Yes ___ No If not, please indicate what language is spoken _____________ PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM
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Date Enrolled _______________________ Permit _______ Transferred from _____________________________ Cum ___________________
Books ________________ Health Records______________ Withdrew to ______________________________________ Date ______________

IN CASE OF EMERGENCY WHEN DESIGNATED PARENT(S) CAN NOT BE LOCATED, WHOM SHALL WE CONTACT ?

1st Choice:
Name
Relationship to student _____________________________________ Address ___________________________________________________________ Phone Number _____________________________
2nd Choice:
Name _______________________________________________ Relationship to student _____________________________________
Address __________________________________________________________ Phone Number ______________________________
Name of Family Doctor______________________________ Phone # _______________ Choice of Hospital _____________________
Indicate any pertinent health problems or conditions, (list routine medications, glasses, contact lens, etc. attach sheet if necessary)
Allergies to: medications/environmental/food?_______________________________________________________________________
Symptoms or reactions:___________________________________________________________________________________________
1.) Do you approve of first-aid treatment for your child when necessary? YES _____ NO _____
2.) Do you consent to your child being permitted to take Acetaminophen /Generic Tylenol at school when needed? YES _____ NO _____
3.) In the event that all efforts to reach me in case of illness or injury of my child should fail, I hereby give my permission to the
school principal and/or authorized school personnel to follow the most suitable procedure to secure the medical attention
needed for my child and I will assume responsibility for the necessary expenses involved. Health Insurance_________Policy #______________
4.) Indiana Law requires: All 1st, 4th, 7th, and 10th grade students must be screened for hearing and all 1st, 3rd, and 8th grade students must be screened
5. Indiana Law IC 20-34-4-2 stipulates immunizations required by grade level. Immunization records are to be submitted on the first day of enrollment. 6.) Medication must be brought to school in a labeled prescription bottle with a permission slip signed by the Physician. If over the counter medication is needed, a note from the parent with the student name/dose and date is required. Unused medication must be picked up by the parent or someone designated by the parent who is over age of 18 for students in grades K-8. 7.) The appropriate forms for medical or religious objections to immunizations may be obtained @www.vigoschools.org or at your school. Signature of Parent/Guardian ___________________________________ Date _____________________________ _______________ Health Records______________ Withdrew to ______________________________________ Date ______________

Source: http://linapp.vigoco.k12.in.us/public/Emergency%20Card%20x2013.pdf