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Series 506.2.1.3P - Emergency Information - Early Childhood

Adopted: December 1987
Revised: June 2012

Home Phone (______) ______–__________ ❏ Unlisted Birthdate __________________________________
Address _______________________________________________________ City _____________________________ Zip _______________ e-mail:_______________________________________
Parent or Guardian Information
1. (Last name, First name) _________________________________________________________________________________________ Code _________
Home Phone (_____) _____–_________ Work Phone (_____) _____–_________ Cellular (_____) _____–_________ Other (_____) _____–_________
Address ______________________________________________________________________________________________________________________
City _________________________________________________________ State __________ Zip _______________ e-mail:________________________________________________________
2. (Last name, First name) _________________________________________________________________________________________ Code _________
Home Phone (_____) _____–_________ Work Phone (_____) _____–_________ Cellular (_____) _____–_________ Other (_____) _____–_________
Address ______________________________________________________________________________________________________________________
City _________________________________________________________ State __________ Zip _______________ e-mail:________________________________________________________
Day Care Information: Name ___________________________________________________________________________________________________________Phone (_____) _____–___________
List two neighbors or relatives who will assume temporary care of child if you cannot be reached.
Name_________________________________________________ Address ______________________________________________________________________ Phone (_____) _____–___________
Name_________________________________________________ Address ______________________________________________________________________ Phone (_____) _____–___________
In case of serious accident or illness and I cannot be reached, I hereby authorize Dr. ________________________ to give necessary treatment. You may call him/her at phone (_____) _____–_________
Name and school for brothers or sisters presently attending school ____________________________________________________________________________________________________________
Severe allergies (i.e., to bee stings, peanuts, milk, etc.) ________________________________________ Describe____________________________________________________________________
 __________________________________________________________________________________________________________________________________ Med. Asst. Eligible ❏ No ❏ Yes
Current medical information to be added to health record, i.e., immunization, illness, surgery ______________________________________________________________________________________
Significant chronic health concerns (diabetes, etc.) and current medication(s)________________________________________________________________________________________________
__________________________________ Teacher____________________________ Grade________
Student’s Last Name First Middle
❏ Male ❏ Female
To Parent or Guardian:
     The welfare of your child is our first consideration. In case of the serious injury or illness of a student in school, the following steps will be taken immediately: The school nurse will be called; emergency line
911 will be called, if deemed necessary, and you or the person designated on this emergency card will be called. If none of the persons listed can be reached, school personnel will implement emergency procedures
to protect the health and safety of your child. It is your responsibility to make arrangements for proper care in case your child is injured or becomes too ill to stay in school when you are away from home.
     There have been instances when we could not reach parents or guardians of injured or ill children because this card was not accurate. Please complete this card so we can keep our records up-to-date
and initiate emergency care quickly. This information is confidential. Your signature acknowledges that this information will be maintained both at school and on the bus. If there are any significant changes in your
child’s health, please call to keep your child’s school nurse informed.
Code (relationship to student)
F = Father G = Guardian
M = Mother X = Self
S = Step parent GP = Grandparent
P = Foster parent
O = Other ___________________
Series Number _____________________ Adopted ______________________ Revised _____________________ Title__________________________________________________________________ 506.2.1.3P December 1987 June 2012 Emergency Information – Early Childhood
Data Privacy Advisory
Pursuant to Minnesota Statutes 13.04, Subd. 2, you are hereby informed that the information supplied on this form may be used by school personnel that have a need to know the information in the event
of an emergency. This may include teachers, principals, nurses or other school staff. You are not legally required to provide the information requested in this form, however failure to supply requested
information may inhibit emergency procedures. In the event of an emergency, the information supplied on this form may be shared with other public and private individuals including, but not limited to, law
enforcement personnel, doctors or paramedics, or listed emergency contact persons.
Bus Rider
❏ Yes
❏ No
Emergency Contact Information
Early Childhood
Independent School District 196
Rosemount - Apple Valley - Eagan Public Schools
PRP/Procedure/500 Series/506.2.1.3P.indd/District 196 Graphics/6-20-12
X Signature of Parent or Guardian____________________________________________________ Date________________