Skip to main content

Mechanicsburg Area School District

Mobile Menu Toggle
District Home
Admin
District Forms » Student Emergency Information Form

Student Emergency Information Form

Student Emergency Information Form

MASD Beginning of Year Student Emergency Information Verification

 

 

The following information is required for each MASD student at the beginning of each school year.  

 

Please read the following information carefully.  You will be asked to verify all contact and health information.  

You will also be asked to provide permission for various school-related items for your child

(ex. media, medication permission, etc.).

After you read the information, verify its accuracy and indicate the appropriate permissions, please sign

the bottom of this form.

Military Family

Is the student's parent and/or guardian currently an active duty member of a branch of armed

forces.  Including full time Reserve or National Guard duty.             YES             NO

 

Contact Information – MOTHER

 

Title      _______First Name______________________Middle_____________Last_________________

Contact Lives With Student         Yes            No

Address_____________________________________________________________________________

City       _________________________________________State              _______________Zip Code_________   

Township _______________________________________County_______________________________             

                                                            

 

Phone Number

Receives Voice Calls

Receives Text Messages

Emergency Call Order

Phone 1                                         

 

 

 

 

Phone 2                           

 

 

 

 

Phone 3                                                                     

 

 

 

 

Phone 4             

 

 

 

 

Phone 5             

 

 

 

 

Email Addresses

 

 

 

 

Email 1

 

 

 

 

Email 2

 

 

 

 

Email 3

 

 

 

 

Occupation             

 

 

 

 

Employer             

 

 

 

 

 

Contact Information – FATHER

 

Title      _______First Name______________________Middle_____________Last_________________

Contact Lives With Student         Yes            No

Address_____________________________________________________________________________

City       _________________________________________State              _______________Zip Code_________   

Township _______________________________________County_______________________________             

                                                            

 

Phone Number

Receives Voice Calls

Receives Text Messages

Emergency Call Order

Phone 1                                         

 

 

 

 

Phone 2                           

 

 

 

 

Phone 3                                                                     

 

 

 

 

Phone 4             

 

 

 

 

Phone 5             

 

 

 

 

Email Addresses

 

 

 

 

Email 1

 

 

 

 

Email 2

 

 

 

 

Email 3

 

 

 

 

Occupation             

 

 

 

 

Employer             

 

 

 

 

 

 

Contact Information – OTHER

 

Title      _______First Name______________________Middle_____________Last_________________

Contact Lives With Student         Yes            No

Address_____________________________________________________________________________

City       _________________________________________State              _______________Zip Code_________   

Township _______________________________________County_______________________________             

                                                            

 

Phone Number

Receives Voice Calls

Receives Text Messages

Emergency Call Order

Phone 1                                         

 

 

 

 

Phone 2                           

 

 

 

 

Phone 3                                                                     

 

 

 

 

Phone 4             

 

 

 

 

Phone 5             

 

 

 

 

Email Addresses

 

 

 

 

Email 1

 

 

 

 

Email 2

 

 

 

 

Email 3

 

 

 

 

Occupation             

 

 

 

 

Employer             

 

 

 

 

 

 

 

 

 

 

 

Health Information

Hospital Preference        

 

 

Primary Care Physician Name

 

 

Physician Phone

 

 

Physician Fax    

 

 

Address

 

 

City      

 

 

State    

 

 

Zip Code            

 

 

Dentist Name

 

 

Physician Phone             

 

 

Physician Fax    

 

 

Address

 

 

City      

 

 

State    

 

 

Zip Code            

 

 

 

 

List All Allergy Information

 

 

 

List All Medical Condition Information

 

 

Medications taken at Home

 

Standing Order Medication -

The nurse has my permission to administer the following medications as needed: (Please circle YES or NO)

 

 Acetaminophen/Tylenol      YES    NO                                   Ibruphophen   YES     NO

 Antibiotic Ointment              YES    NO                                           Motrin      YES     NO

 Antifungal Cream                  YES    NO                              Hydrocortisone     YES    NO

 Bacitracin                                YES   NO

 Benadryl                                  YES   NO

 Calcium Carbonate (Tums, Rolaids)   YES     NO

 Chloraseptic Spray                 YES    NO

 Chloraseptic Throat Spray    YES   NO

 Diphenhydramine                  YES   NO

 Epinephrine/Epi-Pen             YES   NO

Permission Information

Code of Conduct and Student Handbooks *       

Does the school district have your permission to include your child's name and picture in a school yearbook (if one is published)? * YES        NO

Do you approve the release of the following information to be included in the PTO handbook? (Student Name, Teacher/Grade, Parent/Guardian's Name, Address, Phone and Email)         YES        NO

Publicity - School District *Does the school district have your permission to include recordings (audio, video, or photograph) of your child in district publications? (Examples of district approved digital media include, but are not limited to, yearbook, seesaw, the district website and calendar.)       YES                     NO

Publicity - Media - Does the school district have your permission to release recordings (audio, video, or photograph) of your child to the media (Examples of district approved digital media include, but are not limited to newspaper, television, radio, and social media)?                YES                     NO

 

High School Only

 

Military Permission

Pursuant to the Federal No Child Left Behind Act (20 U.S.C. 7908), the Mechanicsburg Area School District must disclose to military recruiters and institutions of higher learning, upon request, the names, addresses and telephone numbers of high school students.

 

The district must also notify parents/guardians of their right and the right of their child to request that the district not release such information without prior written consent.

 

Parents/Guardians wishing to exercise their option to withhold their consent of the release of the above information to military recruiters or to institutions of higher learning must select DO NOT ALLOW CONTACT in the box below.

___Allow Contact                                 _____Do Not Allow Contact

 

Bring Your Own Device (High School Only) *          

Electronic Instructional Resources

Your student will have access to district approved electronic instructional resources throughout the school year.  (Examples of district approved electronic instructional resources include, but are not limited to, Google Apps for Education, IXL, iReady, etc.)  These electronic instructional resources enhance the district curriculum and provide students with a richer experience both in and out of the classroom.  Students must adhere to the MASD Acceptable Use Policy (815) when using these electronic instructional resources.  Violations may result in termination of use of these resources.

 

Parent Verification - By signing below you are providing validating your responses to the above.

 

_____________________________________