Microsoft word - emergency procedure card
FAMILY NAME ________________________________________
Student ________________________________________Grade ___ Phone ______________________
Student ________________________________________Grade ____
Address_____________________________________________________________________________
IN CASE OF EMERGENCY OR EARLY DISMISSAL, PLEASE INDICATE WHO IS TO BE NOTIFIED
IN PRIORTY ORDER.
(Please list on back of form those authorized to check out your child.)
( ) Mother ______________________________________Phone_________________________Cell_______________________
( ) Father ______________________________________ Phone ________________________ Cell ______________________
( ) Grandparent ________________________________ Phone________________________ Cell ______________________
( ) Grandparent ________________________________ Phone________________________ Cell ______________________
( ) Physician ____________________________________ Phone ________________________
( ) Hospital _____________________________________ Phone ________________________
( ) Other desired procedure_________________________________________________________________________________
E-mail Address____________________________________________________________________________________________
Important Numbers ________________________________________________________________________________________
Allergies _______________________________________ Chronic Conditions _________________________________________
May give ( ) Tylenol ( ) Benadryl ( ) Sudafed ( ) Other _________Child_____________________________
May give ( ) Tylenol ( ) Benadryl ( ) Sudafed ( ) Other _________Child_____________________________
EMERGENCY PROCEDURE FORM 20__ - 20__
FAMILY NAME ________________________________________
Student ________________________________________Grade ___ Phone ______________________
Student ________________________________________Grade ____
Address_____________________________________________________________________________
IN CASE OF EMERGENCY OR EARLY DISMISSAL, PLEASE INDICATE WHO IS TO BE NOTIFIED
IN PRIORTY ORDER.
(Please list on back of form those authorized to check out your child.)
( ) Mother ______________________________________Phone_________________________Cell_______________________
( ) Father ______________________________________ Phone ________________________ Cell ______________________
( ) Grandparent ________________________________ Phone________________________ Cell ______________________
( ) Grandparent ________________________________ Phone________________________ Cell ______________________
( ) Physician ____________________________________ Phone ________________________
( ) Hospital _____________________________________ Phone ________________________
( ) Other desired procedure_________________________________________________________________________________
E-mail Address____________________________________________________________________________________________ Important Numbers ________________________________________________________________________________________ Allergies _______________________________________ Chronic Conditions _________________________________________
May give ( ) Tylenol ( ) Benadryl ( ) Sudafed ( ) Other ______________Child_______________________
May give ( ) Tylenol ( ) Benadryl ( ) Sudafed ( ) Other ______________Child_______________________
ADDITIONAL INFORMATION
Name ________________________________________________ Phone _______________________
Name________________________________________________ Phone________________________
Name ________________________________________________ Phone _______________________
Name________________________________________________ Phone________________________
Name________________________________________________ Phone________________________
PLEASE MAKE SURE THE FRONT IS MARKED FOR DISPENSING OF MEDICATION
ADDITIONAL INFORMATION
Name ________________________________________________ Phone _______________________
Name________________________________________________ Phone________________________
Name ________________________________________________ Phone _______________________
Name________________________________________________ Phone________________________
Name________________________________________________ Phone________________________
PLEASE MAKE SURE THE FRONT IS MARKED FOR DISPENSING OF MEDICATION
Source: http://www.westbrookchristianschool.org/documents/Emergency%20Procedure%20Card.pdf
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