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.). 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 |
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Contact Information – MOTHER
Title _______First Name______________________Middle_____________Last_________________
Contact Lives With Student Yes No
Address_____________________________________________________________________________
City _________________________________________State _______________Zip Code_________
Township _______________________________________County_______________________________
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Phone Number |
Receives Voice Calls |
Receives Text Messages |
Emergency Call Order |
Phone 1 |
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Phone 2 |
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Phone 3 |
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Phone 4 |
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Phone 5 |
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Email Addresses |
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Email 1 |
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Email 2 |
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Email 3 |
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Occupation |
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Employer |
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Contact Information – FATHER
Title _______First Name______________________Middle_____________Last_________________
Contact Lives With Student Yes No
Address_____________________________________________________________________________
City _________________________________________State _______________Zip Code_________
Township _______________________________________County_______________________________
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Phone Number |
Receives Voice Calls |
Receives Text Messages |
Emergency Call Order |
Phone 1 |
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Phone 2 |
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Phone 3 |
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Phone 4 |
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Phone 5 |
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Email Addresses |
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Email 1 |
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Email 2 |
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Email 3 |
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Occupation |
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Employer |
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Contact Information – OTHER
Title _______First Name______________________Middle_____________Last_________________
Contact Lives With Student Yes No
Address_____________________________________________________________________________
City _________________________________________State _______________Zip Code_________
Township _______________________________________County_______________________________
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Phone Number |
Receives Voice Calls |
Receives Text Messages |
Emergency Call Order |
Phone 1 |
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Phone 2 |
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Phone 3 |
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Phone 4 |
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Phone 5 |
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Email Addresses |
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Email 1 |
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Email 2 |
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Email 3 |
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Occupation |
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Employer |
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Health Information
Hospital Preference |
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Primary Care Physician Name |
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Physician Phone |
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Physician Fax |
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Address |
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City |
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State |
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Zip Code |
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Dentist Name |
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Physician Phone |
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Physician Fax |
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Address |
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City |
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State |
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Zip Code |
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List All Allergy Information |
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List All Medical Condition Information |
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Medications taken at Home |
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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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