Dear Parent:

During the course of a school year, emergencies could arise or situations occur that

would necessitate medical and/or dental treatment. Sometimes it is difficult to reach you during

and emergency, and delay in time could be harmful to the health of your child. If this happens

we would like to have your permission to take your child to your family physician and/or dentist

if the need arises at any time during the school year. This would conserve time on the part of our

health services personnel and alleviate the necessity of contacting you prior to treatment. This

would also insure a more orderly procedure in obtaining treatment and insure the health and well

being of your child.

Since the malpractice question has come to the forefront, many hospitals and doctors will

not treat a child without parent’s consent (unless it is a matter of life and death). It is requested

that you complete the information below so that if you child requires emergency medical

treatment while under supervision of the school, this will allow the hospital and doctors to treat

the injury.

EMERGENCY INFORMATION

Student’s Name: Sex: M ______F______

Grade: _____ Age: _____ Date of Birth:_____/______/______SS# ______

Parent’s Name:______

Home 911 Address:______

Home Phone # ______

Father’s SS # ______Mother’s SS # ______

Father’s workplace ______Mother’s workplace ______

Father’s Phone @ work ______Mother’s Phone @ work ______

Another person to contact: ______

Relationship: ______Phone: ______

Insurance Name: ______

Policy and Group Numbers: ______

Allergies: ______

Doctor’s Name: Phone: ______

Dentist Name: Phone: ______

Parental Consent for Emergency Medical Treatment

If my child needs emergency medical or dental treatment, and the doctor/dentist of my choice is

not available, the school has permission to obtain treatment by an available doctor, dentist, or hospital. Iunderstand that every effort will be made to contact each person listed above.

______

PARENT SIGNATURE Date

The OneidaSpecialSchool District maintains a strict policy regarding with whom your

child/children will be allowed to leave the school grounds. Only those persons listed below will

be allowed to take the children from school. Any additions or deletions from this list must be

submitted in writing to the school office prior to any situation requiring pick up permission.

  • IT MUST BE NOTED THAT THE SCHOOL WILL ASK THE NAMED

PERSONS BELOW FOR IDENTIFICATION VERIFICATION.*

STUDENT NAME: ______

THE PERSONS LISTED BELOW ARE ALLOWED TO PICK UP MY CHILD

NAMEPHONE #

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

Special information or instructions: ______

______

IF THE COURT HAS GIVEN CUSTODY TO A PARENT/GUARDIAN, THE SCHOOL MUST HAVE A COPY TO PLACE IN THE CHILD’S RECORD.

______

Parent/Guardian SignatureDate