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.

 

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