File:† JLCE-E

 

 

 

School First Aid and Emergency Medical Care Card

 

Student information

 

Name ____________________________ Address __________________________

 

ID number _________________________ Grade _______________

 

Date of birth ________________________

 

 

Medical/Physician information

 

Physicianís Name ________________________ Phone No. ___________________

 

Hospital Preference ___________________________________________________

 

Insurance Company __________________________________________________

 

Dentistís Name _________________________ Phone No. ____________________

 

Known medical conditions/concerns: _____________________________________

 

___________________________________________________________________

 

Known allergies to medicines/drugs: ______________________________________

 

Minor injury

I understand that in the case of minor injury* school district personnel shall administer first aid and send my child back to class.

 

Serious injury (but not threatening to life, limb or digit)

In the event my child is in pain or requires medical treatment beyond first aid for a serious, but not life/limb or digit threatening, injury*, I understand the school district will attempt to contact me (or any of the persons I have listed below) so that I can obtain medical treatment for my child.

 

Severe injury (threatening to life, limb or digit)

In the event my child suffers a severe injury or illness requiring immediate medical attention*, I understand that school district personnel will call 911 to notify emergency health personnel.† School personnel will then attempt to contact me (or any of the persons I have listed below) so that I may proceed to the hospital.

 

(*as determined by appropriate school district personnel)

 

I hereby authorize, consent to, and agree to be responsible for any costs associated with, the transportation of my child, including ambulance service, and any medical tests, procedures and/or treatment performed on my child as deemed necessary by a medical health professional.

 

Contact information

 

Parent/guardian ______________________ Phone No. ______________________

 

Parent/guardian ______________________ Phone No. ______________________

 

Other contact __________________________ Phone No. ____________________

 

Relation to student ________________________

 

I understand that school district personnel cannot be held liable for any good faith effort to provide emergency care or assistance to my child.

 

Parent/guardian signature _______________________________________

 

Date ________________________________

 

 

Please keep a copy of this form for your records.† Important:† Please update your school immediately if any information changes.