5125.1

Students

Emergency Card Information

An Emergency Card system has been developed as a means to contact parents/guardians or other persons designated by parents or guardians in the event of an emergency involving their child.

The system requires parents/guardians to provide accurate and timely information pertaining to where they and/or their designees can be contacted in the event of such an emergency.

When parents do not provide accurate and timely information, a letter will be sent to them from the building administrator indicating to them that such information constitutes a condition for attending the Manchester Public Schools. Should the information not be provided within a period of two weeks of the initial notification, a second letter shall be sent by the building administrator. This notice shall indicate that the child will no longer be permitted to continue in attendance unless the requested information is received within two weeks.

Failure to comply will result in written notification to the parent/guardian that they may request, in writing, a hearing by the Manchester Board of Education in accordance with Connecticut General Statute 10-186. If aggrieved by the finding, the parent/guardian may appeal the decision to the State Board of Education

Legal Reference: CT General Statute 10-186

Adopted: April 10, 1989
Revised: May 12, 2003

(PLEASE PRINT)

Student's Name (last) _______________________________ (first) _______________________ (middle name) ________________

STUDENT EMERGENCY CARD

School Year ___________________ School ______________________ Grade/Team _____________
To Parent or Guardian:
Please complete both sides of two cards for each student. White card will be filed in school office and the blue will be filed with the School Nurse. Information on this document will be shared with the transportation company and emergency personnel as needed.

Student's Address (Street) __________________________________________ (City) ______________________ Zip _____________

Home Phone ________________________________ D.O.B. ______________________ (Circle ) Male Female

The following information MUST be on file in case of accident, illness or other non-medical emergency.
Student resides with: (circle) Mother Father Both Parents Guardian Other

1. Parent/Guardian Name _______________________________________ Relationship ______________ Phone (____)___________
Parent/Guardian DOB________________
Address ________________________________________________________ Cell Phone/Beeper (____)_______________

Father/Guardian Employed at: ______________________________________________ Phone (____)_______________

2. Parent/Guardian Name _________________________________________ Relationship _____________ Phone (____)__________
Parent/Guardian DOB _______________
Address _______________________________________________________ Cell Phone/Beeper (____)__________________

Mother/Guardian Employed at: ______________________________________________ Phone (____)_________________

__________________________________________________________________________________________

For School Use Only: Student I.D. # ___________________ Pentamation updated: _____________

In case parent/guardian cannot be reached, the school may contact and, if necessary, release the child to:

1. Name ____________________________________________________________ Home Phone (____)__________________
Date of Birth ___________________________ Cell Phone (____)__________________
Address ___________________________________________________________ Work Phone (____)__________________

2. Name ____________________________________________________________ Home Phone (____)__________________
Date of Birth __________________________ Cell Phone (____)__________________
Address ___________________________________________________________ Work Phone (____)__________________

Describe any specific medical condition you are aware of that may require emergency treatment, such as allergies, seizures and
asthma.

List all medications: ______________________________________________________________________________

Is your child able to verbalize these medical problems? Yes No

Family Physician _____________________________________________________________ Phone _____________________

Date of Last Appointment _______________________________

In case of an accident or serious illness, the school will attempt to contact me. If the school is unable to reach me, I hereby authorize the school to contact our physician and to follow his or her instructions. If unable to contact our family physician, I understand my child will be transported to the nearest hospital for emergency care and treatment.

I have received a copy of my child's Parent/Student Handbook and I understand the policies and procedures regarding medical, e.g. (accident or illness) and non-medical, e.g. (transportation, discipline). I have reviewed this document with my child. I understand it is my responsibility to update the school on information changes and new telephone numbers.

_____________________________________________
StEm Card 8/03 Parent/Guardian Signature Date