Garfield Re-2 Policies

JLCE-E-First Aid and Emergency Medical Care

JLCE-E

First Aid and Emergency Medical Care

Student’s name______________________________________________________

Grade_____Date of birth________________Social security number_____________

___________________________________________________________________

Street address City Zip code Telephone number

___________________________________________________________________

Mailing address City Zip code

Emergency calls: Mother’s name and work number_________________________

Father’s name and work number__________________________

Please list one or more other telephone number of persons who may be contacted in the event that parents are not available in case of emergency.

Name__________________________telephone_________relationship__________

Health information: List all health conditions that may exist such as heart disease, allergies, eye or ear problems, etc., and any precautions that should be taken in the event of occurrence:

Condition(s)_________________________________________________________

Precaution(s)________________________________________________________

Doctor________________________________telephone______________________

I, the undersigned, do hereby authorize officials of Garfield Re-2 School District to contact directly the persons named on this form and do authorize such treatment as may be deemed necessary in an emergency for the health of my child. I will not hold the district responsible in any way, financially or otherwise, for the emergency care and/or transportation of my child.

Kindly notify the school if any of the above information should change during this school year.

Signature of parent/guardian____________________________________________

Issued: November 26, 1996

Garfield School District No. Re-2, Rifle, Colorado

J - Students