Fillable Printable NJ Family Care Emergency Medical Form - New Jersey

NJ Family Care Emergency Medical Form - New Jersey

Guardian

Address Address

NAME OF SCHOOL DISTRICT

____________________________________________________________________

ID#__________________________________

Last Name____________________________ First____________________Initial_____ Date of Birth (Mo/Day/Year)___________________

Address________________________________________________________________ School_____________________________________

City____________________________________________Zip_____________________ Grade______________________________________

Home Telephone (_____)__________________________________________________ Teacher/H.R._______________________________

To Parent or Guardian: To serve your child in case of accident or sudden illness, it is necessary that you give the following information for emergency calls:

Name Address Telephone

Mother/_________________________________ Home ____________________________________ ________________________________

Work ____________________________________ ________________________________

Father _________________________________ Home ____________________________________ ________________________________

Work ____________________________________ ________________________________

List two neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached:

Name_____________________________________________________ Name_____________________________________________________

Home/____________________________________________________ Home/____________________________________________________

Work/_____________________________________________________ Work/_____________________________________________________

Telephone: Home___________________ Work___________________ Telephone: Home___________________ Work___________________

Relationship________________________________________________ Relationship________________________________________________

Please list other children attending New Jersey Public Schools (Name, School)

_________________________________________________________ __________________________________________________________

■ Please check this box if there has been a name change of parent/guardian, address or telephone number.

Does this child have any health insurance including NJ FamilyCare/Medicaid, Medicare, private or other?

Yes_______ If Yes, name of insurance company _________________________________________________________________________

No _______ NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents.

For more information call 800-701-0710 or visit www.njfamilycare.org to apply online.

You may release my name and address to the NJ FamilyCare Program to contact me about health insurance.

Signature: _____________________________ Printed Name: ______________________________ Date:_______________

List any medical/surgical care your child has received during the past year:

______________________________________________________________________________________

Dental Exam ______________________________ ______________________________

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Eye Exam ______________________________ ______________________________

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Allergy ______________________________ ______________________________

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Allergic Reaction ______________________________ ______________________________

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Immunizations/Tetanus ______________________________ ______________________________

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Restrictions ________________________________________________________________

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Doctor _______________________________________________________________________ Telephone ____________________________

Dentist _______________________________________________________________________ Telephone ____________________________

Hospital ____________________________ Address __________________________________ Telephone ____________________________

I, the undersigned, do hereby authorize officials of New Jersey Public Schools to contact directly the persons named on this card and do authorize the named

physicians to render such treatment as may be deemed necessary in an emergency, for the health of said child.

In the event that physicians, other persons named on this card, 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 not hold the school district financially responsible for the emergency care and/or transportation for said child.

______________________________________________________________________________________________________________________

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Written consent required pursuant to 20 U.S.C. § 1232g (b)(1) and 34 C.F.R. 99.30 (b).