Duval County Public Schools
Authorization for Emergency Care

STUDENTS NAME_______________________      STUDENT #________________

SCHOOL______________________________ 	  DATE OF BIRTH____________

HOME ADDRESS_______________________________________  GRADE_________

CITY________________________________	  HOME PHONE_______________

TO PARENT OR GUARDIAN: To serve your child in case of ACCIDENT OR SUDDEN
ILLNESS, it is necessary that you furnish the following information for
emergency calls:

            PARENT/GUARDIAN   BUSINESS ADDRESS        BUSINESS TELEPHONE

MOTHER      _______________   ____________________    __________________

FATHER      _______________   ____________________    __________________

List two neighbors or nearby relatives who will come to the school to
transport your child home and/or assume temporary care of your child if
you cannot be reached:

Name____________________  Address_____________________ Phone___________

Name____________________  Address_____________________ Phone___________

HEALTH INFORMATION: List any health conditions such as heart disease,
diabetes, epilepsy, severe allergies, eye or ear problems, or other
chronic conditions.

Condition/Explanation:__________________________________________________

________________________________________________________________________


DOCTOR:	1st Choice_______________________ Phone number________________

	2nd Choice_______________________ Phone number________________


Hospital Choice:____________________________ Phone number_______________

I, the undersigned, do hereby authorize officials of Duval County Public
Schools to contact directly the persons named on this form and do 
authorize the named physicians to render such treatment as may be deemed 
in an emergency for the health of said child.

In the event physicians, other persons named on this form, or parents
cannot be contacted, the school officials are hereby authorized to take 
whatever action is deemed necessary in their judgement for the health of 
the aforesaid child.

I will assume full financial responsibility for the emergency care and/or 
transportation for said child and will not hold the school district 
financially responsible.


		_____________________________________________________
		Signature of Parent/Guardian		Date