VIP ACCESS AND EMERGENCY INFORMATION CARD /
Student: ______/ Student # ______/ D.O.B. ______/ Grade______
Last Name First Middle
Parent/Guardian Information:
Home Phone: ______/ Cell Phone: ______E-mail Address: ______/ Pager: ______
Address: ______City: ______Zip: ______
______
Parent/Guardian: ______/ Parent/Guardian: ______
Employed By: ______/ Employed By: ______
Phone @ Work: ______/ Phone @ Work: ______
Person(s) who will care for child in case parent/guardian cannot be reached; these individuals may sign my child out (photo I.D. required):
Name: ______/ Relationship: ______Phone: ______
Name: ______/ Relationship: ______Phone: ______
Name: ______/ Relationship: ______Phone: ______
First and last names of brothers/sisters attending Pasco County Schools ______
______
Person(s) who MAY NOT legally contact or remove my child from school (provide legal documentation): ______
______
It is the parent/guardian’s responsibility to keep the school updated with new information and contact numbers
PARENTAL CONSENT
I hereby give my consent for my child, ______, to participate in the School Health Services Program. This means that my child is eligible to receive vision, hearing, scoliosis, and blood pressure screening at certain grade levels. In addition, the curriculum of some courses is designed by third-party vendors and may include material pertaining to health issues such as abstinence, substance abuse prevention, dating and relationship issues, birth control, and sexually transmitted diseases. If I object to any of these health screenings or programs, I will notify the Pasco eSchool in writing. I understand that, in cases where graded coursework relates to these topics, my child will be required to complete an alternate assignment designed by the online instructor. I further understand that, if my child does not complete the primary or alternate assignment, a grade of zero will be recorded for the work.
In case of accident or serious illness, I want to be contacted by Pasco eSchool. If the school is unable to reach me, I hereby authorize the school to contact the physician or dentist listed below and to follow his/her instructions. If it is impossible to contact this physician or dentist, the school will take whatever actions are necessary to provide care and treatment for my child, and exchange medical information with the provider as necessary to support the continuity of care for my child. I agree to pay all of the expenses incurred by the handling of this emergency care. In case of an accident or illness where immediate treatment of my child is not indicated, but where he/she is unable to remain at school, I request that one of the persons listed on the reverse side of this form by contacted and requested to care for my child until I can be reached.
List any medication(s) your child is currently taking: ______
List any health problems or allergies of which the school should be aware: ______
Does your child’s health problem(s) impact his/her learning ability? Yes ______No ______If yes, explain: ______
Physician’s Name: ______ / Phone: ______Hospital Preference: ______ / Phone: ______
Dentist’s Name: ______ / Phone: ______
If my child is covered by Medicaid and receives health services under an IEP/TIEP, I consent for the school district to bill Medicaid for those services. I also hereby acknowledge by responsibility to transport my child to the testing facility designated by Pasco eSchool for required assessments, including FCAT/SAT-10, and FAIR.
Current Medicaid Card: Yes ______No ______Medicaid Number: ______
My signature indicates my parental consent, understanding, & agreement:
______
Date ______