Billerica Public Schools Middle School Emergency Form 2017 - 2018 7 Dear Parent/Guardian’ z Every precaution is taken to keep your child well and safe in school. However, illness and accidents do oceur. Kindly fill out the e following and return to school promptly, = Student's Nam Date of Birth: Grade: z dent's Names Oe eee Parent/Guardian #2 i Primary Parent Contact Parent/Guardian #2 Cl erimaryParent Contact| & First Name (above) Last Name FirstName (above) ast Name o Address: — ~ Address ~ “Gis pCa Zl z Ustby Cong reference o stor foremllasfestpreference (Cee One) List by Caling Preference or tor for emai preference (Cree One) celywork/Home cell Work/Home Phone Phone wi _ on _eliWork/Home celiork/Home Phone W Phone #2 at _ CeliWork/Home Cell Work/Home Phone #3 Phone #3 7 ~ “Email Address: | ‘ccupation/Place of Employment Coccupation/Pace of Employment: Does a member of your family serve in the miltary? Check here [1 What is the primary language spoken at home?, | Names of at least two LOCAL persons who may be calle and to whom your child may be released if you cannot be reache | ¥ First Name, (above) ~— ast Name First Name (above) ast Name = & ee Celiwerk/Home _ - celywork/tiome | & Phone # Phone Wi z _ _ Celi Work/Home cellWork/Home Phone Phone #2 Relationship to child Relationship to child: _ {n cate of medical emergency, the school wil attempt to contact parent/guardian befor calling student’ primary cre provider (physician). ‘Yur child wil be transported by ambulance to an emergency cae facility if necessary. Al physicians’ orders must be renewed annually. A physician's signature and parental consent must be obtained prior to any medication administration, Any student taking any medication, including | verthe-counter medlatons,n school shor term o ng term, must compiy with the mescation poy of illerice Publi chooks, alYorms can | @ tbe downloaded by going tothe "Health Services" portion af the ailerca Public Schools’ Web se 1B Doctor'sName: Phone: _ |? Health insurance Carer: No Health inurance? Checkhere O)—_ Dentist’ Name: Phone: os Onthodontist's Name: — Phone: | “Dental insurance Carter: ‘No Dental insurance? Check here Ol | Pease list any allergy, illness oF other condition the schoo! nurse should be aware of: Please lst any recent surgery and/or any activity restriction the child may have: _ | All Physical Education excuses are ve atthe begining ofthe school year. Please provide documentation for any immunizations your child has recelved during the last year: _ By signing this form, consent tothe 3 items listed directly below, unless "No" is checked off: 1. give permission for my child to receive the following at the dscrtion ofthe nurse: acetaminaphen, chewable antace tablets, z cal palncliver tip ointment, antiseptic rinse, topical antibiotic ointment, fst ald spray/oinment, petroleum ly, topical anti 3 itch medication, stele saline eye wash; in accordance with the school physician's standing orders. woo | % 2. Forte health and safety of my chi, | ge permission forthe school nurse to share certain medical information about my child 3 with the appropriate schoo! personnel on a need to know basis, e.g. food allergies, bee sting allergies, asthma ora medical noo |g condition that may become a concern at school. . 3. eve permission fr the schoo! nurse to cally chil physician f needed, nwo | = : ae UENO” is checked off for any tem above, please contact the schoo! nurse.) | Parent/Guardian Signature Dat