Student Emergency Contact Card 2021-2022
In the case of an emergency, it is imperative that the school be able to reach the student's parent (as defined below). Please complete this form carefully and accurately . The names of both parents of a student (as defined in the Section 1000.21(5), Florida Statutes), the registering parent, of a student shall be listed on the emergency card as persons authorized to pick up the child from school except where a court order has revoked the parental rights and a certified copy of such court order has been provided to the school office.

Both parents shall designate on the Emergency Contact Card those persons authorized to pick their child up from school. No parent shall delete or in any way alter the names provided by the other parent on the Emergency Contact Card.
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Student Information
Student Last Name *
Student First Name *
Date of Birth *
MM
/
DD
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Grade Level *
Gender *
Home Address  (Street Number & Name, City, State, Zip Code) *
Home Phone *
Student lives with *
Required
If you selected "other" for the question above, please state the relationship and name of the person the student resides with below
Check any that apply to student residence *
Required
Has student changed address since last registration? *
Is there a court order on file that prevents a parent from having contact with the student? *
Registering Parent
Name *
Home Address  (Street Number & Name, City, State, Zip Code) *
Home Phone *
Cell Phone *
Work Phone *
Email Address *
Employer *
Other Parent
Name
Home Address  (Street Number & Name, City, State, Zip Code)
Home Phone
Cell Phone
Work Phone
Email Address
Employer
Authorized Release/ Contact
Please list the names of persons to whom we may release your child or whom we may contact if we cannot reach you. NO STUDENT WILL BE RELEASED TO ANYONE OTHER THAN THE PERSONS LISTED HERE. In selecting someone whom you authorize to release your child, consider: Is the person prepared to handle any special medical needs required by your child? By listing this information below, I/We hereby authorize contact with, release of emergency related information, or release of the student ti the following persons in the event of illness, evacuation, or other emergency that may occur while the student is in school.
Authorized Person #1
Name
Relationship
Phone Number
Authorized Person #2
Name
Relationship
Phone Number
Authorized Person #3
Name
Relationship
Phone Number
Medical Information
Please list any medications taken by your child including dosage and hours given.                                   For Example: (Ibuprofen 200mg at 8:00am and 2:00pm)
Health Insurance Information *
Does your child wear glasses/contacts? *
Does your child wear a hearing aid? *
Physician Name
Physician Phone Number
Medical Conditions - Check all that apply
If your child has asthma, do they use an inhaler?
Clear selection
If your child has seizures, are they on medication?
Clear selection
If your child has diabetes, are they insulin dependent?
Clear selection
Release of Medical Information
By typing my name (in the signature section) and today's date below, I authorize for my child's medical information, parental contact information, and other health information (provided from health services provided at school, including information stored electronically) to be shared with emergency personnel and health department officials to address conditions of public health importance, including information to meet and to prepare for potential or confirmed health conditions.
Signature
Today's Date
MM
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DD
/
YYYY
Dismissal Information
On a typical day, how will your child leave school? *
In the event of a severe storm or other unscheduled emergency dismissal your child is instructed to
Clear selection
Siblings
Please list any siblings at our school along with their current grade level     For Example: John Brown - 2nd
Survey Questions
Please assist us in better understanding the needs of our school community by answering the following questions.
Does your child have access to a computer at home?
Clear selection
Do you have home internet access?
Clear selection
Does your child have access to the internet on your home computer?
Clear selection
Do you have internet access outside your home?
Clear selection
Do you have internet access outside your home?
Clear selection
Please indicate the method of contact you prefer.
Clear selection
Submit
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