Online Blue Card - Emergency Location and Health Survey Information

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Please enter all required information, read the attached documents, and acknowledge that you've read them before submitting the form.

Email *

Students Last Name *

Student's First Name *

Student's Middle Name (type n/a if no middle name) *

Student's grade level *

6th Grade

7th Grade

8th Grade

Student's Birthday *

YYYY

Student's Home Address: street,city, and zip code *

Home Phone *

Father/Guardian Name *

Father/Guardian Place of Business or Work *

Father/Guardian Contact Number(s) *

Mother/Guardian Name *

Mother/Guardian Place of Business or Work *

Mother/Guardian Contact Number(s) *

Indicate which Parent/Guardian should be contacted first *

Father/Guardian

Mother/Guardian

Primary Email Address *

Secondary Email Address *

In case of Illness or emergency, contact the following person if Parent/Guardian cannot be located:

Emergency Contact Name & Relationship *

Emergency Contact Phone Number *

Preferred Hospital & Phone Number *

For your child's safety, medical information may be shared with appropriate school staff on a need to know basis.

Does your child have any of the following conditions listed below? Please indicate by checking any and all health conditions your child has. *

Food Allergy (specify in next section

Insect Allergy (specify in next section)

Seasonal Allergy

Other Allergy

Vision Trouble

Head Injury/Concussion

ADD/ADHD

Bone/Muscle Problem

Diabetes

Hemophilia

Activity Restrictions (specify in next section)

Cancer (specify in next section)

Sickle Cell Disease

Hearing Loss

Heart Trouble

High Blood Pressure

Seizures

Bladder/urinary problems

Kidney Disease

Bowel problems

Asthma

Daily meds for asthma

Inhaler at school

NONE

Other:

Required

Specify Details:

Specify Other

Indicate date of last asthma episode:

YYYY

Additional comments regarding your child's health.

Has your child has any overnight hospital visits in the past 12 months? *

Yes

What was the reason for the hospital visit?

Has your child had any ER visits in the past 12 months? *

Yes

What was the reason for the ER visit?

Describe special needs the student has that are associated with physical, emotional, mental, or behavioral conditions (for example: needs frequent bathroom breaks, carries Epi-Pen, or uses wheel chair). Type N/A if your child does not have any special needs.

Insurance Provider: *

Insurance Number: *

HMO :

Medicaid #:

Emergency Dismissal

In the event that school is dismissed earlier than scheduled when students return to the building:

How will your child be getting home if students are dismissed before the scheduled end of the school day? *

Bus

Car

School Forms

There are several important forms linked below. Please read through the forms with your child and initial in each section to indicate that you have read and understood the forms. Click the following link to read each form: https://schools.cms.k12.nc.us/baileyMS/Pages/Back-to-School-Forms.aspx

Please enter your initials to indicate that you and your child have read and understand the "Bailey Honor Code". *

Please enter your initials to indicate that you and your child have read and understand the "Bailey Grading Policy". *

Please enter your initials to indicate that you and your child have read and understand the "Bailey Remote Learning Expectations (student/staff/parent)". *

The CMS Student Code of Conduct is being updated and will available on the Bailey website. Please initial to indicate that you know where to find this document. *

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