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 |
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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 |
Broward County Public Schools
Student Emergency Contact Card
This form shall be updated every year.
For oice use only:
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Medical |
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Student # |
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Court Order |
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Special Needs |
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Date enrolled |
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Other |
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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
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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Registering Parent |
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IdeniicaionNumber: |
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Other Parent |
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Student |
Authorized Release/ |
Contact |
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Teacher (elementary school only) |
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Male |
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Female |
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Home Address |
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Home Phone |
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Mailing Address (if diferent from above) |
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Date of Birth |
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Student lives with: |
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Has student changed address |
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Is there a court order on ile that prevents a |
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Check any that apply to student residence: |
since last registraion? |
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parent from having contact with the student? |
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Medical |
Special Needs |
Yes |
No |
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Yes |
No (If yes, contact school.) |
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Court Order |
Other |
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Home Address |
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Employer |
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Work Phone |
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Home Address |
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Home Phone |
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Employer |
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Work Phone |
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Cell Phone |
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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 |
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Relaionship |
This secion may be completed only by the
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 |
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Date |
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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
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
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Does your child |
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If your child requires medicaion at school, all medicaion sent to the school must |
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Yes |
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No |
be in original prescripion container with a current date and the child’s name. Also |
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take medicaion? |
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a “Medicaion/treatment Authorizaion” form, must be completed and signed by |
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the physician and the parent and must be on ile at the school. |
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Medicaion |
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Dosage |
Hour(s) Given |
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Please check appropriate |
Family Health Insurance |
Florida Healthy Kids |
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Florida Kid Care |
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box: |
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Medicaid # |
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No Health Insurance |
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Does your child wear |
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Does your child wear |
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No |
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contacts/glasses? |
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hearing aid(s)? |
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Name |
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Physician |
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Denist |
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Health Plan/Group Name |
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Check all that apply: |
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Asthma |
If checked, uses inhaler? |
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On daily medicaion? |
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Seizures |
If checked, on medicaion? |
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No |
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Diabetes |
If checked, insulin dependent? |
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No |
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Movement Limitaions |
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Recent illness/hospitalizaion/surgery |
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(describe) |
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Other |
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Severe allergies? If checked, please specify: |
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Food/environmental |
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Allergies require: |
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Insect sings/bees |
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EpiPen |
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Medicines/Drugs |
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Benadryl |
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Other |
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Other |
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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 |
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Date |
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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 |
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emergency medical care as deemed necessary. Emergency transportaion to a health care facility, as determined by paramedics, will be authorized. |
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REGULAR DISMISSAL PROCEDURES |
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EMERGENCY DISMISSAL PROCEDURES |
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On a typical school day, how will your child leave school? |
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In the event of a severe storm or other unscheduled emergency |
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Ride in car |
Ride School Bus |
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dismissal your child is instructed to: |
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Walk/bike home |
Atend |
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Walk home |
Ride school bus as usual |
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Ride public |
program |
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Ride public transportaion |
Ride home with |
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Atend |
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Ride home with parent only |
friend as indicated on |
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transportaion |
program |
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authorized contact list |
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Please list any siblings at our school |
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Please list any other languages spoken at home: |
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Last Name |
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First Name |
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Grade Level |
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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 |
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Do you have home internet access? |
Yes |
No |
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Does your child have access to the internet on your home computer? |
Yes |
No |
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Do you have internet access outside your home? |
Yes |
No |
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Please indicate the method of contact you prefer: |
Text |
Phone |
FORM 4172 REVISED 05/15