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    Medicalform

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    api-257833418
    This document is an emergency treatment authorization card for a student. It provides the student's name, date of birth, grade, school, allergies, medical conditions, emergency contacts, and health insurance information. The parent agrees to the school providing emergency medical treatment and holds the school harmless. The parent signature confirms reading and understanding the terms of the card in order to authorize emergency medical care for the student.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medicalform

    Uploaded by

    api-257833418
    40 views1 page
    This document is an emergency treatment authorization card for a student. It provides the student's name, date of birth, grade, school, allergies, medical conditions, emergency contacts, and health insurance information. The parent agrees to the school providing emergency medical treatment and holds the school harmless. The parent signature confirms reading and understanding the terms of the card in order to authorize emergency medical care for the student.

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    medicalform

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    This document is an emergency treatment authorization card for a student. It provides the student's name, date of birth, grade, school, allergies, medical conditions, emergency contacts, and health insurance information. The parent agrees to the school providing emergency medical treatment and holds the school harmless. The parent signature confirms reading and understanding the terms of the card in order to authorize emergency medical care for the student.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    40 views1 page

    Medicalform

    Uploaded by

    api-257833418
    This document is an emergency treatment authorization card for a student. It provides the student's name, date of birth, grade, school, allergies, medical conditions, emergency contacts, and health insurance information. The parent agrees to the school providing emergency medical treatment and holds the school harmless. The parent signature confirms reading and understanding the terms of the card in order to authorize emergency medical care for the student.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    EMERGENCY TREATMENT AUTHORIZATION CARD-English

    SCHOOL BOARD OF ORANGE COUNTY, Florida

    (Please Print)

    Students Legal Name:___________________________________________________

    School: ________________________________

    Students Date of Birth:__________________________________________________

    Date of last tetanus shot:_________________________________________

    Grade:___________

    My child is allergic to the following medications:_____________________________________________________________________________________________


    My child has the following allergies:_______________________________________________________________________________________________________
    Please identify any serious injuries or illnesses your child has had: _______________________________________________________________________________
    Alternate family member/friend to contact in case of emergency Name: __________________________________________________________________________
    Telephone Number (s):__________________________________________________________________________________________________________________
    Primary Care Doctor Name:_______________________________________________________________ Telephone Number:_______________________________
    You understand that the insurance offered by Orange County Public Schools is a secondary policy and will pay only after your personal insurance pays.
    Please write none if you have no personal insurance on this student.
    Primary Insurance Company: _______________________________________________________ Policy Number:_________________________________________
    Insurance Company Address:_____________________________________________________________________________________________________________
    You understand if a parent, guardian or student falsifies any signature or information on the emergency medical treatment card, the student will be declared ineligible
    to participate in any Orange County interscholastic activity for one full calendar year from disclosure date. You further give your permission for appropriate school
    staff and their designees to render medical treatment or authorize medical treatment by a hospital and/or doctor and agree to hold the School Board and its employees
    harmless in the administration of such assistance. I hereby acknowledge and certify that I have read the emergency medical document, that I understand and agree
    with its terms. Florida Statutes (92.525) Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true. I agree to be
    bound by its terms and I have reviewed and explained the notice with my child.
    _______________________________________________
    Signature of Parent/Legal Guardian

    _______________________________________________________
    Print Name of Parent/Legal Guardian

    ______________
    Date

    Telephone (H)__________________________________ Telephone (W)_______________________________________ Other______________________________


    Street Address:_________________________________________________
    City: ____________________________________________

    Email Address _________________________________________________________

    State: __________________________________

    Zip: ________________________________
    70530

    TARJETA DE AUTORIZACIN PARA TRATAMIENTO DE EMERGENCIA-ESPAOL

    JUNTA ESCOLAR DEL CONDADO ORANGE, FLORIDA (Letra de Molde)

    Nombre Legal del Estudiante: ______________________________________________ Escuela: ___________________________________ Grado: ___________


    Fecha de Nacimiento del Estudiante: ________________________________________Fecha de la ltima vacuna contra el ttano: ___________________________
    Mi hijo(a) es alrgico a las siguientes medicinas: ____________________________________________________________________________________________
    Mi hijo(a) tiene las siguientes alergias: ____________________________________________________________________________________________________
    Favor de identificar cualquier lesin seria o enfermedades que su hijo(a) ha tenido: _________________________________________________________________
    Miembro de familia/Amigo alterno que pueda contactarse en caso de emergencia: _________________________________________________________________
    Nombre: __________________________________________________________________ Nmeros de telfono: _______________________________________
    Nombre del Mdico de Cuidado Primario: ______________________________________________________ Telfono: __________________________________
    Usted comprende que el seguro ofrecido por las Escuelas Pblicas del Condado Orange es una pliza secundaria y pagar slo despus de que haya pagado su seguro
    personal.
    .
    Por favor escriba ninguno si no tiene seguro personal para este estudiante.
    Compaa Primaria de Seguros: _______________________________________________ Nmero de Pliza: __________________________________________
    Direccin de la Compaa d e Seguros: ___________________________________________________________________________________________________
    Usted comprende que si un padre, encargado o estudiante falsifica cualquier firma o informacin en la tarjeta para tratamiento mdico de emergencia, el estudiante
    ser declarado inelegible para participar en cualquier actividad interescolar del Condado Orange durante un ao calendario completo a partir de la fecha del
    descubrimiento. Usted adicionalmente concede su permiso para que el personal apropiado de la escuela y sus asignados ofrezcan tratamiento mdico o autorice
    tratamiento mdico por parte de un hospital y/o mdico y acepta librar a la Junta Escolar y sus empleados de responsabilidad en la administracin de tal asistencia.
    Por la presente reconozco y certifico que he ledo el documento de evaluacin deportiva, que comprendo y acepto sus trminos. Estatuto de Florida (92.525) Bajo
    pena de perjurio, declaro que he ledo lo anterior y que los hechos presentados son verdicos. Acepto estar sujeto a sus trminos y he revisado y explicado la
    notificacin a mi hijo(a).
    _________________________________________________ _____________________________________________
    _____________________________
    Firma del Padre/Madre/Encargado Legal
    Nombre del Padre/Madre/Encargado Legal
    Fecha
    Telfono (H)_____________________________________ Telfono (O) _______________________________________ Otro: ___________________________
    Direccin: _________________________________________________________________________________________________________________________
    Ciudad:
    Estado:
    Cdigo Postal:

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