NOTE: While Colorado school districts are not required by law to adopt a exhibit on this subject, CASB believes this sample contains the content/language that reflects "best practices." However, the district should consult with its own legal counsel to determine appropriate language that meets local circumstances and needs.
Student information
Name ____________________________ Address __________________________
ID number _________________________ Grade _______________
Date of birth ________________________
Medical/Physician information
Physician´s Name ________________________ Phone No. ___________________
Hospital Preference ___________________________________________________
Insurance Company __________________________________________________
Dentist´s Name _________________________ Phone No. ____________________
Known medical conditions/concerns: _____________________________________
___________________________________________________________________
Known allergies to medicines/drugs: ______________________________________
Minor injury
I understand that in the case of minor injury* school district personnel shall administer first aid and send my child back to class.
Serious injury (but not threatening to life, limb or digit)
In the event my child is in pain or requires medical treatment beyond first aid for a serious, but not life/limb or digit threatening, injury*, I understand the school district will attempt to contact me (or any of the persons I have listed below) so that I can obtain medical treatment for my child.
Severe injury (threatening to life, limb or digit)
In the event my child suffers a severe injury or illness requiring immediate medical attention*, I understand that school district personnel will call 911 to notify emergency health personnel. School personnel will then attempt to contact me (or any of the persons I have listed below) so that I may proceed to the hospital.
(*as determined by appropriate school district personnel)
I hereby authorize, consent to, and agree to be responsible for any costs associated with, the transportation of my child, including ambulance service, and any medical tests, procedures and/or treatment performed on my child as deemed necessary by a medical health professional.
Contact information
Parent/guardian ______________________ Phone No. ______________________
Parent/guardian ______________________ Phone No. ______________________
Other contact __________________________ Phone No. ____________________
Relation to student ________________________
I understand that school district personnel cannot be held liable for any good faith effort to provide emergency care or assistance to my child.
Parent/guardian signature _______________________________________
Date ________________________________
Please keep a copy of this form for your records. Important: Please update your school immediately if any information changes.
[Reviewed April 2015]
COLORADO SAMPLE EXHIBIT 2002©