Crown Point Elementary School

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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
     
     

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:

Name Phone Number
1st choice  
2nd choice  

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