CONFIDENTIAL

STAFF EMERGENCY FORM

NAME: _________________________________________________     DOB                                    

ADDRESS: ______________________________________________     SCHOOL                             

IN CASE OF AN EMERGENCY PLEASE CONTACT:

NAME: ______________________________________     RELATIONSHIP                                       

HOME PHONE________________________________     WORK PHONE:                                        

IF UNABLE TO REACHE ABOVE PERSON, PLEASE CONTACT:

NAME_______________________________________      RELATIONSHIP:                                     

HOME PHONE: ______________________________      WORK PHONE:                                         

PHYSICIAN’S NAME:                                                                                                                             

CLINIC LOCATION:____________________________________   PHONE:                                       

OPTIONAL INFORMATION

This portion of the emergency form is optional. The information would be shared in the event that an emergency situation would arise while working in the District.

CURRENT MEDICATIONS:                                                                                                                   

CURRENT/CHRONIC HEALTH CONCERNS THAT THE SCHOOL/NURSE SHOULD KNOW ABOUT?

DO YOU GO INTO SHOCK OR HAVE DIFFICULTY BREATHING WHEN STUNG BY AN INSECT?

YES_______     NO_______

IF YES, DO YOU CARRY AN EPI-PEN?                                                                                                

I UNDERSTANT THAT THE ABOVE INFORMATION WILL BE SHARED WITH THE APPROPRIATE STAFF/AND OR MEDICAL PERSONNEL, IN THE EVENT THAT I WOULD NEED MEDICAL ASSITANCE WHILE WORKING IN THE SCHOOL DISTRICT.

STAFF SIGNATURE: __________________________________________    DATE