Form 4172 ≡ Fill Out Printable PDF Forms Online

Broward Schools Emergency Contact Form Details

Form 4172 is a form that businesses use to report their annual income tax. The form is used to calculate the amount of tax that the business owes to the government. Businesses are required to submit Form 4172 if they meet any of the following conditions: They have $5,000 or more in sales revenue They have $500 or more in expenses They had at least one employee working for them during the year They had at least $1,000 in gross receipts from renting property, products, or services They owe any other taxes such as employment taxes or excise taxes.

You will discover information about the type of form you would like to prepare in the table. It will tell you the amount of time you'll need to complete form 4172, what fields you will have to fill in, and so forth.

Question	Answer
Form Name	Form 4172
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Providers, student emergency contact card broward school, Broward, sports forms for broward county schools

Form Preview Example

Broward County Public Schools

Student Emergency Contact Card

This form shall be updated every year.

For oice use only:

School #				Medical

Student #				Court Order
				Special Needs
Date enrolled
				Other

In the case of an emergency, it is imperaive that the school be able to reach the student’s parent (as deined below). Please ill in the informaion on both sides of this card carefully and accurately. Please use ink and print clearly. The names of both parents of a student (as deined in the Secion 1000.21(5), Florida Statutes), the registering parent and the non-registering parent, of a student shall be listed on the emergency contact card as persons authorized to pick up the child from school except where a court order has revoked the parental rights and a ceriied copy of such court order has been provided to the school oice.

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.

	Student
Grade:

	Registering Parent
IdeniicaionNumber:	Registering Parent
IdeniicaionNumber:	Other Parent
Student	Authorized Release/	Contact

Student:

Non-registering Parent Authorized Release/Contact

Last

First

Middle

Teacher (elementary school only)

Gender

Male

Female

Grade Level

Home Address

City

State

Zip

Home Phone

Mailing Address (if diferent from above)

City

State

Zip

Date of Birth

Student lives with:

Has student changed address

Is there a court order on ile that prevents a

Check any that apply to student residence:

since last registraion?

parent from having contact with the student?

Medical

Special Needs

Yes

No (If yes, contact school.)

Court Order

Other

Last

First

Home Address

City

State

Zip

Home Phone

Employer

Work Phone

Cell Phone

Last

First

Home Address

City

State

Zip

Home Phone

Employer

Work Phone

Cell Phone

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 BELOW. In selecing someone to whom you authorize the release of your child, consider: Is this person prepared to handle any special medical needs required by your child? I/We hereby authorize contact with, release of emergency related informaion, or release of the student to the following persons in the event of illness, evacuaion, or other emergency that may occur while the student is in school.

NameRelaionshipHome PhoneWork or Cell Phone

I declare that the informaion on this card is true and correct. I will noify the school oice immediately of any changes.

Signature

Date

Relaionship

This secion may be completed only by the non-registering parent in order to designate addiional persons who may pick up the student. The registering parent may not alter this secion of this card. The non-registering parent may not alter any other porion of this card.

NameRelaionshipHome PhoneWork or Cell Phone

I declare that the informaion on this card is true and correct. I will noify the school oice immediately of any changes.

Signature

Date

Relaionship

FORM 4172 REVISED 05/15

Broward County Public Schools

Student Emergency Contact Card

The personal informaion you provide on this form will be kept conidenial (in a protected area)

and only used and disclosed by school staf on a need-to-know basis.

Student Name

Medicaion

Health Insurance

Informaion

Vision and

Hearing

Health Care

Providers

Medical Condiions

Release of Medical

Informaion

Emergency

Treatment

Dismissal

Informaion

Siblings and

Home Language

Survey Quesions

Last		First			Middle

Does your child				If your child requires medicaion at school, all medicaion sent to the school must
	Yes		No	be in original prescripion container with a current date and the child’s name. Also

take medicaion?				a “Medicaion/treatment Authorizaion” form, must be completed and signed by
				the physician and the parent and must be on ile at the school.


Medicaion				Dosage	Hour(s) Given

Please check appropriate

Family Health Insurance

Florida Healthy Kids

Florida Kid Care

box:

Medicaid #

No Health Insurance

Other

Does your child wear

Yes

Does your child wear

Yes

contacts/glasses?

hearing aid(s)?

Name

Phone Number

Physician

Denist

Health Plan/Group Name

Check all that apply:

Asthma

If checked, uses inhaler?

Yes

On daily medicaion?

Seizures

If checked, on medicaion?

Yes

Diabetes

If checked, insulin dependent?

Yes

Movement Limitaions

Recent illness/hospitalizaion/surgery

(describe)

Other

Severe allergies? If checked, please specify:

Food/environmental

Allergies require:

Insect sings/bees

EpiPen

Medicines/Drugs

Benadryl

Other

I hereby authorize for my child’s medical informaion, parental contact informaion, and other health informaion (collected from health services provided at school, including informaion stored electronically) to be shared with emergency personnel and health department oicials to address condiions of public health importance, including informaion to meet and to prepare for potenial or conirmed health condiions.

Parent Signature

Date

Medical and other informaion will be disclosed without consent from the parent/eligible student in case of health emergencies, as permissible by FERPA. The school will call for

emergency medical care as deemed necessary. Emergency transportaion to a health care facility, as determined by paramedics, will be authorized.

REGULAR DISMISSAL PROCEDURES

EMERGENCY DISMISSAL PROCEDURES

On a typical school day, how will your child leave school?

In the event of a severe storm or other unscheduled emergency

Ride in car

Ride School Bus

dismissal your child is instructed to:

Walk/bike home

Atend on-site ater-care

Walk home

Ride school bus as usual

Ride public

program

Ride public transportaion

Ride home with

Atend of-site ater-care

Ride home with parent only

friend as indicated on

transportaion

program

authorized contact list

Please list any siblings at our school

Please list any other languages spoken at home:

Last Name

First Name

Grade Level

Please assist us in beter understanding the needs of our school community by answering the following quesions. Please check all that apply.

Does your child have access to a computer in your home?	Yes	No
Do you have home internet access?	Yes	No
Does your child have access to the internet on your home computer?	Yes	No
Do you have internet access outside your home?	Yes	No
Please indicate the method of contact you prefer:	Email	Text	Phone

FORM 4172 REVISED 05/15

Form 4172 – Fill Out and Use

Broward Schools Emergency Contact Form Details

Form Preview Example

Form 4172 isn’t the one you’re looking for?

Form 4172 – Fill Out and Use

Broward Schools Emergency Contact Form Details

Form Preview Example

Form 4172 isn’t the one you’re looking for?

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