OLR Documentation

This pleat is for Emergency Card Information

EMERGENCY CARDS ARE NOT RETAINED FROM ONE SCHOOL YEAR TO THE NEXT. The following information must be completed EVERY SCHOOL YEAR to update your student’s health records.

Please select ONGOING if your child has any of the following health condition(s). If the condition is NEWLY DIAGNOSED this school year and/or not previously reported to the school nurse, please select NEW.

ADD/ADHD:

Allergies:

Allergies to food:

Allergies to insect stings/bites:

Allergies to latex:

Allergies to medication(s):

Allergies to animals:

Allergies seasonal:

Allergies life threatening:

Arthritis Rheumatic:

Asthma:

Autism:

Birth Defect:

Bleeding Disorder:

Cancer:

Cystic Fibrosis:

Diabetes Type 1:

Diabetes Type 2:

Emotional:

Depression:

Bipolar:

Anxiety:

Eating Disorder:

Other:

Endocrine Disorder:

Gastrointestinal Disorder:

Genitourinary Disorder:

Hearing Ear Disorder:

Hearing Aids Cochlear Implant:

Heart Condition:

Neuro Disorder:

Orthopedic Disorder:

Seizure Disorder:

Vision Disorder:

Glasses Contacts:

Other Health Condition:

Daily Medication Regimen

Medication 1:

Dosage 1:

Frequency 1:

Medication 2:

Dosage 2:

Frequency 2:

Medication 3:

Dosage 3:

Frequency 3:

Medication 4:

Dosage 4:

Frequency 4:

Medication 5:

Dosage 5:

Frequency 5:

First and Last Name of Primary Healthcare Provider for Child:*

Healthcare Provider Phone: *

Health Insurance Plan:*

Preference of Local Hospital:*

Emergency Card Guardian Initials:*

PARENT/GUARDIAN SIGNATURE ON THIS FORM ACKNOWLEDGES THE FOLLOWING

1. It is the responsibility of the parent/guardian to update information on this emergency form with appropriate documentation as changes occur.

2. Person(s) listed as emergency contact(s) are permitted to pick up student from school.

3. By entering your initials on the Emergency/Information form and providing your phone number, you are authorizing the school and/or Paradise Valley Unified School District to deliver or cause to be delivered information and notifications regarding your child, the school, and the District via autodialed calls or prerecorded calls. You may request to be removed from future notifications at any time by calling or emailing the school/District or using the opt-out feature when you receive a call.

4. In the event of an accident or illness when authorization for medical treatment cannot be obtained from parent or personal physician, the undersigned gives permission and assumes full responsibility for the school nurse and/or the school administrator to call for emergency medical assistance, including ambulance service.

5. To assure the safety and well-being of my child, the school nurse has permission to share pertinent health concerns with appropriate school personnel.

6. Registration and enrollment for the current school year is incomplete until this emergency form and the Release Consent and Acknowledgment form have been completed and signed by the parent/guardian and submitted to the school.

By clicking the "Next" button you will enter the next pleat, in this case, "Release Agreements"

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