Request for Emergency and Health Information Form
This Emergency and Health Information Form is required by the Chicago Public Schools for parents or guardians to provide critical information. It helps the school to contact parents or guardians in case of emergencies and provide necessary health details. Keep this form updated by notifying the school of any changes.
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How do I fill this out?
To fill out this form, you will need to provide your child's personal information and your contact details. Ensure all fields are completed accurately and legibly. If there are any changes, notify the school immediately.
How to fill out the Request for Emergency and Health Information Form?
1
Enter student information including ID, name, birth date, and home address.
2
Complete the confidential information box if it applies to your situation.
3
Provide parent/guardian contact information and emergency contacts.
4
Indicate any current orders of protection or no contact orders.
5
Submit the form with accurate health insurance details and parent/guardian signature.
Who needs the Request for Emergency and Health Information Form?
1
Parents or guardians to provide emergency contact information for their child.
2
Students who are living independently and need to provide their own contact details.
3
School administrators needing to have updated contact information for all students.
4
Healthcare providers in emergency situations needing to access a student's medical information.
5
Legal authorities needing to know if there are any protection orders related to the student.
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Make the required edits to update your information.
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What are the instructions for submitting this form?
Submit the completed Emergency and Health Information Form to your child's school office. You can submit via email, fax, or in person. Check with your school for the specific submission email or fax number. Make sure all information is filled out accurately and legibly. Keep a copy for your records.
What is the purpose of this form?
The purpose of this Emergency and Health Information Form is to provide Chicago Public Schools with essential contact and health information for students. In case of emergencies, it is crucial for the school to have accurate and up-to-date details to promptly contact parents, guardians, or other designated individuals. Additionally, the form assists in identifying students' health insurance status and any specific living arrangements to ensure they receive the necessary support and services. By providing this information, parents and guardians help the school protect and assist their children effectively.
Tell me about this form and its components and fields line-by-line.
- 1. Student Information: Includes Student ID, Name, Birth Date, Home Address, Homeroom #, and Home Phone #.
- 2. Confidential Information Box 1: Reflects the child's current living situation, relevant for enrollment and additional services.
- 3. Parent/Guardian and Emergency Contact Information: Requires details for parents/guardians and other emergency contacts, including names, relationships, addresses, phone numbers, and permissions.
- 4. Confidential Information Box 2: Indicates if there is a current Order of Protection or No Contact Order concerning the student.
- 5. Family Doctor's Information: Authorizes the school to contact the family doctor in case of an emergency. Includes Doctor's Name, Address, and Phone Number.
- 6. Student Health Insurance: Specifies the type of health insurance the student has and requires relevant details.
- 7. Parent/Guardian Signature: Certifies that the information provided on the form is correct.
What happens if I fail to submit this form?
Failure to submit this form can lead to significant issues in emergencies as the school may not have the necessary information to contact parents or guardians.
- Delayed Emergency Response: Without this form, the school might face delays in reaching out to parents or guardians during emergencies.
- Lack of Medical Information: The absence of health insurance and family doctor details can hinder swift medical assistance.
- Inadequate Support Services: The school may not be able to provide additional services to students with specific living situations.
How do I know when to use this form?
- 1. School Enrollment: Use this form to provide necessary contact and health information during school enrollment.
- 2. Annual Update: Submit this form at the start of each school year to ensure the information is current.
- 3. Change of Address: Fill out a new form immediately if there is a change in the home address or any contact details.
- 4. Change in Living Situation: Update the form if there is a change in the student's living situation to receive additional support.
- 5. Update Health Insurance: Use this form to update health insurance details whenever there are changes.
Frequently Asked Questions
How do I fill out the Emergency and Health Information Form?
You can fill out the form by entering the required details in the provided fields. Ensure all information is accurate and up-to-date.
Can I edit the form after submitting it?
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Can I share the form with others?
Yes, you can share the form using PrintFriendly's share feature. Edit the document, then send it via email or generate a shareable link.
What information is required on the form?
The form requires student details, parent/guardian contact information, emergency contacts, and health insurance details.
Is it necessary to complete the confidential information boxes?
Complete the confidential information boxes only if they apply to your or your child's living situation. This helps the school provide additional services.
Who should be listed as emergency contacts?
List parents/guardians, relatives, neighbors, and any other individuals who can be contacted in case of an emergency and can pick up the student.
How often should I update the form?
Update the form immediately whenever there is a change in your or your child's information to ensure the school has the most current details.
Where do I submit the completed form?
Submit the completed form to your child's school office. They will keep it on file for emergency use.
Can I access the form online?
Yes, you can access, fill out, and edit the form online using PrintFriendly's PDF editor.
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