Kaufman independent school district

Student Medical / Emergency Information Card
Student’s Name ________________________________________________ Date ________________ Address ______________________________________________________ Birth Date____________ Sex _______ TO PARENT OR GUARDIAN: To serve your child in case of accident or illness, please furnish the following information:
Father’s Name ______________________________________ Father’s Home Phone # ______________________ Cell Phone # ______________________ Work Phone # _______________________ Mother’s Name _____________________________________ Mother’s Home Phone # __________________ Cell Phone # ______________________ Work Phone # _______________________ List two persons who will assume temporary care of your child if you cannot be contacted:
Name _________________________________________________ Phone # _________________________ Name _________________________________________________ Phone # _________________________ Doctor ________________________________________________ Phone # _________________________ Dentist ________________________________________________ Phone # _________________________
I do _____________ or do not ______________ carry insurance on ______________________________________________________.
Athlete’s Name

Insurance Provider ____________________________________________________________________________
INSURANCE COMPANY PHONE # NAME OF INSURED I, the undersigned, do hereby authorize employees of Kaufman Independent School District to contact directly the persons and health care providers named on this card, and do authorize the named physicians, clinics, and/or hospitals to render such treatment as may be deemed necessary for the transportation and health care of said child. In the event the physicians, other persons named on this card, or parents cannot be contacted, the school employees are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the aforesaid child. (Section 35.01, Texas Family Code) I will not hold the school district financially responsible for the emergency care and/or transportation for said child. I request that the physicians, dentists and staff of the medical facility perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatments and anesthetics as may be necessary in the diagnosis and treatment of my child. I understand that I must notify Kaufman I.S.D. in writing to change any information on this form or to revoke any consent given herein. I testify all information on this document to be true and correct. Original forms are on file in the KISD athletic office and available for inspection upon request. OVER THE COUNTER MEDICATION
The following Over the Counter (OTC) medications are provided for your student/athlete ONLY with your permission.
Please indicate with a CHECK any medicines you wish to be WITHELD from your child.
____ Antacid (Alcalak)
____ Benadryl (Diphen) *Only given in case of severe allergic reaction* Prescription Medications Currently Taking: __________________________________________________________ Allergic Reactions to Medications, Food or Other: ______________________________________________________ PRINTED NAME OF PARENT/GUARDIAN SIGNATURE OF PARENT/GUARDIAN DATE

Source: http://www.kaufmanisd.net/uploaded/KISD_Athletics/7._Student_Medical-Emergency_Information_card.pdf

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