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2021-2022 FCA Frisco Emergency Contact and Medical Information Form - One Form Per Student
Emergency Treatment Authorization:
In the event that I cannot be reached in an emergency, I hereby give authorization and consent to the school to obtain emergency medical care and necessary emergency transportation to a healthcare facility.
Release of Medical Information:
I understand and authorize that my child’s medical records or other medical information, furnished to the school, will be shared with school officials and emergency personnel who have legitimate medical/educational purpose for accessing such medical records and information.
Medical/Health Information:
All medication for your student must be provided by a parent and be in the original container with current date and the child’s name. An “Authorization for Medication” form must be on file.
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* Indicates required question
Email
*
Your email
Student's Last Name:
*
Your answer
Student's First Name:
*
Your answer
Student's Date of Birth:
*
MM
/
DD
/
YYYY
Student's Gender:
*
Choose
Male
Female
Student's Primary Residence:
*
Your answer
Student Grade:
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Required
List any health conditions such as heart disease, diabetes, epilepsy, severe allergies, eye or ear problems, or any chronic condition, etc. If no health conditions exist, please type "none"
*
Your answer
List allergies such as drugs, tape, latex, adhesive, x-ray, dye, etc. If no allergies exist, please type "none"
*
Your answer
I have read and reviewed the this Emergency Form and confirm that the information is accurate
*
Choose
Yes
No
Primary Parent/Guardian Full Name (this will be your electronic signature)
*
Your answer
Primary Parent/Guardian relationship to student:
*
Choose
Mother
Father
Grandmother
Grandfather
Other
Explain other (please type "none" if this does not apply):
*
Your answer
Primary Parent/Guardian cell phone number:
*
Your answer
Primary Parent/Guardian home phone number:
*
Your answer
Alternate Parent/Guardian Full Name (please type "none" if this does not apply):
*
Your answer
Alternate Parent/Guardian relationship to student:
*
Choose
Mother
Father
Grandmother
Grandfather
Other
Explain other (please type "none" if this does not apply):
*
Your answer
Alternate Parent/Guardian cell phone (please type "none" if this does not apply):
*
Your answer
Alternate Parent/Guardian home phone (please type "none" if this does not apply):
*
Your answer
Alternate Parent/Guardian email address (please type "none" if this does not apply):
*
Your answer
Emergency contact #1 - Full name, cell phone number, and relationship to student:
*
Your answer
Emergency contact #2 - Full name, cell phone number, and relationship to student:
*
Your answer
Emergency contact #3 - Full name, cell phone number, and relationship to student (please type "none" if this does not apply):
*
Your answer
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