Student Emergency Information Card Form PDF Details

Ensuring the safety and well-being of students while they are under school care involves meticulous planning and the gathering of essential information, which is where the Student Emergency Information Card comes into play. This critical document, designed for both elementary and secondary education settings, serves as a comprehensive resource for schools to access vital data about students in case of emergencies. It meticulously collects information starting with the basics: the student’s legal name, birth date, grade, and contact details, including home and cell phone numbers, email address, and home mailing address, with an option to note any changes to the student’s address. The form further delves into family information, specifying details about the student's parents or guardians, their living arrangements, contact numbers, and work information, ensuring there are multiple avenues to reach them or other designated adults if necessary. Moreover, it extends into a crucial area of medical information, requesting details on allergic reactions, medical conditions like asthma, diabetes, seizure disorders, and any medication the student regularly takes, ensuring that the school is prepared to handle medical emergencies with informed precision. Signatures from parents or guardians authorize school personnel to administer first aid or secure medical care in emergencies, signifying the trust placed in educational institutions to safeguard their wards. Given its exhaustive approach to collecting detailed personal and medical information, the Student Emergency Information Card embodies the foresight educational institutions exercise in prioritizing student safety.

QuestionAnswer
Form NameStudent Emergency Information Card Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesstudent emergency card, emergency cards for students, emergency card template, emergency card

Form Preview Example

Student Emergency Information Card

FOR OFFICE USE ONLY: AERIES G

DATE

 

BY

 

 

 

 

 

 

STUDENT’S LEGAL NAME (LAST – FIRST – MIDDLE)

BIRTH DATE (MM-DD-YY)

 

 

GRADE

 

 

 

 

 

ADDRESS (STREET – CITY – STATE – ZIP)

HOME PHONE

 

STUDENT’S CELL PHONE

 

 

 

 

 

MAILING ADDRESS (BOX OR STREET – CITY – STATE – ZIP)

STUDENT’S E-MAIL

 

 

 

 

 

 

STUDENT’S SIGNATURE

 

STUDENT’S LICENSE PLATE NUMBER

G CHECK IF THIS REFLECTS ADDRESS CHANGE

FAMILY INFORMATION

G Father

G Stepfather

LIVING WITH STUDENT

G Guardian

 

 

 

G Yes G No

 

 

 

 

PARENT/GUARDIAN NAME

 

 

 

 

 

ADDRESS, IF NOT LIVING WITH STUDENT (Street Address, City, Zip Code)

 

 

 

 

 

HOME PHONE

 

PAGER

 

CELL PHONE

 

 

 

 

 

PARENT’S E-MAIL

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

WORK PHONE

 

 

 

 

 

G Mother

G Stepmother

LIVING WITH STUDENT

G Guardian

 

 

G Yes G No

 

 

 

 

PARENT/GUARDIAN NAME

 

 

 

 

 

 

ADDRESS, IF NOT LIVING WITH STUDENT (Street Address, City, Zip Code)

 

 

 

 

 

HOME PHONE

 

PAGER

 

CELL PHONE

 

 

 

 

 

PARENT’S E-MAIL

 

 

 

 

 

 

 

 

EMPLOYER

 

 

WORK PHONE

 

 

 

 

 

In case the student’s parent/guardian cannot be reached, the school will contact and/or release the student to the following adults:

ADULT NAME

DAY-TIME PHONE

CELL PHONE

RELATIONSHIP TO STUDENT / FAMILY

 

 

 

 

1.

2.

3.

≡ COMPLETE OTHER SIDE ≡

F5141.1A 8/85; Revised 5/19/10 (doc)

Student Emergency Information Card

FOR OFFICE USE ONLY: AERIES G

DATE

 

BY

 

 

 

 

 

 

STUDENT’S LEGAL NAME (LAST – FIRST – MIDDLE)

BIRTH DATE (MM-DD-YY)

GRADE

ADDRESS (STREET – CITY – STATE – ZIP)

HOME PHONE

STUDENT’S CELL PHONE

MAILING ADDRESS (BOX OR STREET – CITY – STATE – ZIP)

STUDENT’S E-MAIL

GCHECK IF THIS REFLECTS ADDRESS CHANGE

STUDENT’S SIGNATURE

STUDENT’S LICENSE PLATE NUMBER

FAMILY INFORMATION

G Father

G Stepfather

LIVING WITH STUDENT

G Guardian

 

 

 

G Yes G No

 

 

 

 

PARENT/GUARDIAN NAME

 

 

 

 

 

ADDRESS, IF NOT LIVING WITH STUDENT (Street Address, City, Zip Code)

 

 

 

 

 

HOME PHONE

 

PAGER

 

CELL PHONE

 

 

 

 

 

PARENT’S E-MAIL

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

WORK PHONE

 

 

 

 

 

G Mother

G Stepmother

LIVING WITH STUDENT

G Guardian

 

 

G Yes G No

 

 

 

 

PARENT/GUARDIAN NAME

 

 

 

 

 

 

ADDRESS, IF NOT LIVING WITH STUDENT (Street Address, City, Zip Code)

 

 

 

 

 

HOME PHONE

 

PAGER

 

CELL PHONE

 

 

 

 

 

PARENT’S E-MAIL

 

 

 

 

 

 

 

 

EMPLOYER

 

 

WORK PHONE

 

 

 

 

 

In case the student’s parent/guardian cannot be reached, the school will contact and/or release the student to the following adults:

ADULT NAME

DAY-TIME PHONE

CELL PHONE

RELATIONSHIP TO STUDENT / FAMILY

1.

2.

3.

 

 

 

 

 

 

≡ COMPLETE OTHER SIDE ≡

 

 

F5141.1A 8/85; Revised 5/19/10 (doc)

 

Siblings:

Name:

 

 

 

 

 

Age:

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

Age:

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

Age:

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL INFORMATION (please check YES or

NO)

 

 

 

 

 

 

 

 

 

 

 

 

Allergic Reactions

G Yes

G No

If yes, type of allergies:

 

 

 

 

 

 

Asthma

 

 

G Yes

G No

If yes, type of medication taken:

 

 

 

 

 

 

Diabetes

 

 

G Yes

G No

If yes, type of treatment:

 

 

 

 

 

 

Seizure Disorders

G Yes

G No

If yes, what type of seizure:

 

 

 

 

 

 

Medication taken regularly

G Yes

G No

If yes, list type(s) of medication, dosage, and schedule:

 

 

Note—If your child needs to take medication during the regular school day, a form must be signed by the parent/guardian AND the health care provider before the student can take the medication. You can obtain this form at the school office.

OTHER MEDICAL CONDITIONS:

DOCTOR:

 

Address:

 

 

Phone: (

)

HEALTH INSURANCE CARRIER:

 

 

 

 

Policy Number:

I /WE authorize the District’s authorized personnel to administer first aid and to obtain medical care for my child,

in the event of an emergency, illness, accident, or injury (including necessary transportation). I/WE authorize such care and treatment to be performed by any licensed physician or surgeon. I/WE agree to bear all costs incurred as a result of the foregoing.

Father / Guardian Signature

Date

Mother / Guardian Signature

Date

F5141.1A 8/85; Revised 5/19/10 (doc)

Siblings:

Name:

 

 

 

 

 

 

 

 

 

 

Age:

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

Age:

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

Age:

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL INFORMATION (please check YES or

NO)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergic Reactions

G Yes

G No

If yes, type of allergies:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asthma

 

 

 

 

G Yes

G No

If yes, type of medication taken:

 

 

 

 

 

 

 

 

 

 

Diabetes

 

 

 

 

G Yes

G No

If yes, type of treatment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Seizure Disorders

G Yes

G No

If yes, what type of seizure:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication taken regularly

G Yes

G No

If yes, list type(s) of medication, dosage, and schedule:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note—If your child needs to take medication during the regular school day, a form must be signed by the parent/guardian

 

 

 

 

 

 

AND the health care provider before the student can take the medication. You can obtain this form at the school office.

OTHER MEDICAL CONDITIONS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOCTOR:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (

)

 

 

 

HEALTH INSURANCE CARRIER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

I /WE authorize the District’s authorized personnel to administer first aid and to obtain medical care for my child,

 

 

 

 

 

 

 

 

 

 

 

 

 

in the event of an emergency, illness, accident, or injury (including necessary transportation).

I/WE authorize such care and treatment to be performed by any licensed physician or surgeon. I/WE agree to bear all costs incurred as a result of the

foregoing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father / Guardian Signature

 

 

 

 

 

Date

 

Mother / Guardian Signature

 

 

Date

F5141.1A 8/85; Revised 5/19/10 (doc)

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1. While completing the student emergency card, be certain to complete all of the important blanks in its corresponding part. It will help to expedite the work, which allows your details to be processed swiftly and appropriately.

Completing segment 1 of student emergency card template

2. Your next step would be to fill out the next few fields: In case the students, ADULT NAME, DAYTIME PHONE, CELL PHONE, RELATIONSHIP TO STUDENT FAMILY, COMPLETE OTHER SIDE FA Revised, Student Emergency Information Card, FOR OFFICE USE ONLY AERIES G DATE, STUDENTS LEGAL NAME LAST FIRST, G CHECK IF THIS REFLECTS ADDRESS, BIRTH DATE MMDDYY, HOME PHONE, STUDENTS EMAIL, STUDENTS SIGNATURE, and FAMILY INFORMATION.

Part no. 2 for filling in student emergency card template

Be extremely attentive when filling out Student Emergency Information Card and STUDENTS SIGNATURE, because this is the part in which most users make errors.

3. Completing PARENTGUARDIAN NAME, PARENTGUARDIAN NAME, ADDRESS IF NOT LIVING WITH STUDENT, ADDRESS IF NOT LIVING WITH STUDENT, HOME PHONE, PAGER, CELL PHONE, HOME PHONE, PAGER, CELL PHONE, PARENTS EMAIL, EMPLOYER, WORK PHONE, PARENTS EMAIL, and EMPLOYER is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

student emergency card template completion process shown (step 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - Siblings, Name, Name, Name, Age, Age, Age, School, School, School, MEDICAL INFORMATION please check, Allergic Reactions, G Yes, G No, and If yes type of allergies - to proceed further in your process!

student emergency card template completion process shown (part 4)

5. Now, this last part is what you should finish before finalizing the form. The blank fields at issue are the next: Siblings, Name, Name, Name, Age, Age, Age, School, School, School, MEDICAL INFORMATION please check, Allergic Reactions, G Yes, G No, and If yes type of allergies.

student emergency card template conclusion process clarified (stage 5)

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