STUDENT EMERGENCY CARD

Berke1ey Um'fied Sch00ID'IStric t Please Print in Ink

Student'S Last Name First Name Middle Name Helalth'Alerf
<nY~f :
Birthdate (mmJddIyy) Grade Room Teacher Parent/Guardian ematl address
/ /
Home Address City Home Telephone
rIP Code
( )
Parent/Guardian Employer and City Work Telephone Cellular Telephone
( ) ( )
Parent/Guardian Employer and City Work Telephone ~enu1ar Telephone

( ) ( )
~q"o local . _el'lean'ia.l'dlaa"~ll4I haveqrced ' t~'; ~e"tlt"'er tuI~"'ry car.· (la calC .of nhU~) OJ: extcad*d ~ ~e,(l~ · . . ' .
ca. . .r.atar.1 di...ter}
. .. . yo.r ·~Jalld f.r Yoa:
0'.
y.ar cllUd'ln '" pareatlpardlaa .a.nt lIe ' 1'cat"'~, TII.'Wnoa :wo.,1d eo~cte}'c 1C1i1tOIa.d pte\:
. . . .: ,;" . . ' ., ' ".-; '.. ~" • L.}'
Name Work Telephone Home Telephone Re1ationship
( ) ( )
Name Work Telephone Home Telephone Re1ationship
( ) ( )
Health ConcernslDiagnoses: asthma o diabetes o o seizures o severe allergies
Oother(s) -- please list:
(Requires a Special Care Plan onfilefor each condition)
Medications to be taken at school (list all, including emergency medications):

(R£Quires AuJhorization Fonn on file (or each medication)

Form 76 No. 1-8905 Revised 06/07 An previous editions are obsolete Continued on other side

Fonn 76 No. 1-8905 Revised 06/07 STUDENT EMERGENCY CARD

An previous editions are obsolete Berkeey
1 Um'fied Sch00J D'IstriCt Please Print in Ink
Student's Last Name First Name Health Plan Policy no,!Record no.

Does someone other than the parent provide after school care? DYes DNo If so, please list contact information:
Name Address Telephone
( )
Pbysician's Name Address Telephone
( )
Dentist's Name Address Telephone
( )
~ency phone contact outside of the Bay Area that your child could ca1l after an earthquake in order to ~ contact with you thro~h Ii thirdJlarty:
Name ~ Telephone (outside of Bay Area) ( )
J the tmdersigned parent/guardian ofthe student shown above, a minor, do hereby authorize and consent to any x-ray examination, anesthetic,
medical or surgical diagnosis, or treatment and hospital care to be rendered tmder the general or special supervision and upon the advire ofa
physician, surgeon or ~tist under the provisions ofthe Medicine Practire Act, or Dentist Practire Act. Tt is understood that this authorization is
given in advanre ofany specific diagnosis, treatment or hospital carebut is given to provide authority and power for the physician/dentist to render
care which in hislherbestjudgement may be deemed advisable. This authorization is given pursuant to the provisions ofSection 25.8 ofthe CivIl
Code ofCalifomia. It is the responsibility ofthe pareotlguardiaD
to immediately notify the school in writing of any changes in the
infOl"llUltion 00 this tard, Parent/Guardian Signature Date
~tudentRe~bcotd: To be cOlllpleted ONLY
,Office ,Use 01\1y ._~petsonnelf~;t1a1Ura1CJisaster, . ~}:
w1ren ~1cas.iDgacbt1d taan eincrgency .guai"dian«
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 LECONTE SCIENCE MAGNET SCHOOL

2241 RUSSELL STREET

BERKELEY, CA 94705

510/644-6290

DEAR FAMILIES:

It is very important to get some release information for your child, in the
event of an emergency. Please take a moment to fill out the form below
and return it to school AS SOON AS POSSIBLE. It will help us guarantee
the safety and comfort of your child should an emergency situation arise.

Student's Name: Teacher: - - - - -

------------------------
Please list all of the adults that would possibly be picking up your child
(family, friends, neighbors). .

Person's name/relationship: Phone information:

Signature of parenti guardian:___________________________

Extra emergency numbers (cell phone, etc.) for you:

Name / Relationship Number

Name / Relationship Number

 LeConte School
2241 Russell St.
Berkeley, CA 94705
51 0-644-6290

STUDENT FIELD TRIP PERMISSION FORM

I give permission for my child to participate in

all School sponsored field trips as part of the schools regular program. Notice of specific dates and
destinations will be given to me by the teacher.

I understand that my child is to accept all rules and requirements governing conduct during the field
trip. In the event of illness or injury I hereby consent to whatever medical or hospital care from a
licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child.

Signature of parent or guardian Date

Address Phone

Health Insurance Plan Policy Number

Teacher's Name Room Number

In the event of illness or accident, and parent or guardian cannot be reached, please contact:

Name Phone

If your child has any special medical problems, please attach a separate sheet with a description to
this page.

10/11
 LeConte School
2241 Russell St.
Berkeley, CA 94705
510-644-6290

PERMISO DE EXCURSION PARA LOS ESTUDIANTES

Mi nifio/a tiene permiso para ir en las excursiones

programadas para los estudiantes de la escuela LeConte, como parte del programa educativ~ de la escuela.
Los padres seran informados por medio de los maestros los dfas en que estas excursiones se lIevaran a
cabo.

Entiendo y se que mi nifio/a obedecera las reglas durante el viaje. En caso de una emergencia doy permiso
para que mi nifio/a reciba atenci6n medica.

Firma del Padre/Tutor Legal Fecha

Direcci6n Telefono

Nombre de Seguro Medico # de Seguro Medico

Nombre del Maestro/a # de Sal6n de Clase

En caso de un accidente 0 enfermedad y los padres 0 guardianes no puedan ser localizados, por favor
Ilamen a:

Nombre Telefono

Si su hijo/a tiene algun problema medico por favor escrfbalo en una hoja aparte y adjuntelo a esta hoja.

10/11
Berkeley Unified School District

Media Permission

2010 - 2011 School Year

There are many opportunities in which parents, teachers, the press or

others would like to photograph or film our students. The BUSD and our
partners (i.e., the PTA or the Berkeley Public Education Foundation
[BPEFJ) value these images as compelling ways to share and urge
support for the work of our teachers and students. Photo opportunities
arise over the course of the school year, usually with little warning or
time to contact parents for permission. We recognize that some families
would prefer their children not appear, even unidentified, in any print or
electronic media. Having this form on file will ensure that your wishes
are followed. Please complete and return to your school.

o I do not wish to have my child's name or face to be used in any

print or media.

o My child's photograph, with no identification, may be used by

BUSD or its partners (i.e., PTA, BPEF with District approval) in
print or other media related to school events or activities.

o My child's name and photograph may be used by BUSD or its

partners (Le., PTA, BPEF with District approval) in print or other
media related to school events or activities.

Student Name:
-----------------------------------------
School Name: LECONTE ELEMENTARY SCHOOL

Parent/Guardian Signature Date

 Berkeley Unified School District

Parent Authorization for Release of Information to City of Berkeley Public Health Division

Please help us keep your student/s healthy!

BUSD and the City of Berkeley Public Health Division have formed a new partnership to better meet the health
care and health education needs of students and families. Through the School-Linked Health Services Program,
Berkeley Public Health Division win now help BUSD accomplish the following objectives:
• complete documentation and follow-up on immunizations and health screenings,
• work with uninsured families to obtain health insurance and healthcare services,
• assist with the development of care plans for students with unique healthcare needs during the school day,

In order to do this work effectively, The School-Linked Health Services Program needs basic information about
the healthcare status of BUSD students. By signing this document, you are consenting to BUSD sharing with
Berkeley Public Health Division information from the following documents containing information about your
child:
1. Your child's Student Emergency Card
2. Your child's immunization record
3. Your child's results from health screenings conducted at school , including dental, hearing, vision, and
scoliosis
The information supplied in these documents will only be shared with Berkeley Public Health. NO OTHER
ORGANIZATION WILL BE GIVEN THIS INFORMATION. This information will be used by Berkeley Public
Health Division for the following purposes only:
• Contacting families regarding potentially unmet health needs (based on health screening results) and with
information about nollow cost health insurance.
• Assisting the schools with the coordination of care plans for students with unique healthcare needs during
the school day.

Please contact the BUSD Office of Family and Community Partnerships, Maya Hernandez, 644-8991 or City Of Berkeley
School-Linked Health Services Program, Kate Graves, 981-7677 with any questions, comments or concerns.

Please tear offand return to the main office at your childlren 's school
---------------Parent Authorization for Release of Information to Berkeley Public Health---------------­

I consent to BUSD providing healthcare information to City of Berkeley Public Health Division from the
following sources:
• My child ' s Student Emergency Card
• My child's Immunization Record
• My child's results from mandated health screenings (dental, vision, hearing, scoliosis)

Name of School:_ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __

Student's Name: ____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Birthdate: _______

*Signature of ParenUGuardian: Date: _ _ _ _ _ _ _ __
This release is only validfor one year from the date of signature
*California Education Code. Section 49075 states: "A school district may permit access to pupil records to any person for whom a parent of the pupil has executed written
consent specifying the records to be released and identifying the party or class of parties to whom the records may be released. The recipient must be notified that the
transmission of the information to others without the written consent of the parent is prohibited. The consent notice shall be permanently kept with the record file ."
 Distrito Escolar Unificado de Berkeley
Autorizacion del Padre de Familia Para Proporcionar Informacion a la Division de Salud PUblica de la Ciudad de Berkeley

.Por favor ayudenos a mantener a suls estudiante/s saludables!

EI Distrito Escolar de Berkeley (BUSD) y la Divisi6n de Salud Publica de la Ciudad de Berkeley han formado
una nueva colaboraci6n entre sf para servir de una mejor manera el cuidado de salud y las necesidades de
educaci6n referentes a la salud de los estudiantes y sus familias . Mediante el Program a de Servicios de Salud
Entrelazados con la Escuela (School-Linked Health Services), la Divisi6n de Salud Publica de Berkeley ayudani
al BUSD a lograr los siguientes objetivos:
• completar la documentaci6n y realizar un seguimiento en las vacunas y revisiones de salud,
• trabajar con las familias sin seguro medico para obtener dicho seguro y servicios para el cuidado de salud,
• ayudar con el desarrollo de planes para el cuidado de los estudiantes con necesidades de salud unicas durante el dfa
escolar,
En orden de realizar este trabajo de una manera efectiva, El Programa de Servicios de Salud Entrelazados con la
Escuela necesita informaci6n basica acerca del estado de salud de los estudiantes del BUSD.
Alfirmar este documento, usted da su consentimiento para que BUSD comparta con la Division de Salud
Publica de Berkeley informacion acerca de su niiioia la cual se encuentra en los siguientes documentos:
1. Tarjeta de Emergencia de su nino/a
2. Expediente de vacunas de su nino/a
3. Resultados de las evaluaciones de salud de su nino/a que se han realizado en la escuela, dentales, auditivas, visi6n
y escoliosis
La informaci6n que se obtenga en estos documentos sera compartida unicamente con el Departamento de Salud
Publica de Berkeley. ESTA INFORMACION NO SE COMPARTIRA CON NINGUNA OTRA
ORGANIZACION. Esta informaci6n sera usada por la Divisi6n de Salud Publica de Berkeley unicamente para
los siguientes prop6sitos:
• Contactar a las familias en 10 referente a necesidades potenciales de sa Iud que no han sido atendidas (basado en
los resultados de la evaluaci6n de salud) y con informaci6n acerca de seguro medico a bajo/sin costo .
• Asistir a las escuelas con la coordinaci6n de planes para el cuidado de los estudiantes con necesidades de salud
unicas durante el dfa escolar.

Por favor comunfquese con la Oficina de Colaboraci6n con las Familias y la Comunidad, Maya Hernandez,
644-8991 0 con el Programa de Servicios de Salud Entrelazados con la Escuela de la Ciudad de Berkeley, Kate
Graves , 981-7677 con preguntas, comentarios 0 preocupaciones .

Por favor corte y devuelva a fa oficina principal de la escuela de su/s niiio/a/s

---------------Autorizacwn del Padre de Familia Para Proporcionar Informacwn a Salud Publica de Berkeley···········

Yo doy mi consentimiento a BUSD para que provea la informaci6n del cuidado de salud a la Divisi6n de Salud
Publica de la Ciudad de Berkeley de los siguientes documentos:
• Tarjeta de Emergencia de mi nino/a
• Expediente de vacunas de mi nino/a
• Resultados de las evaluaciones de salud de mi nino/a que se han realizado en la escuela (dental, visi6n,
auditiva, escoliosis)
Nombre de la Escuela: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Nombre del Estudiante: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Fecha de Nacimiento: _ _ _ _ __

*Firma del Padre 0 Tutor: _ _ _ _ _ _ _ _ _ _ _ _ _ __ Fecha: _ _ _ _ _ _ _ __

Esta autorizaci6n es valida unicamente por un ana a partir de la fecha de la firma

*EI C6digo de Educaci6n de California, Secci6n 49075 declara: "Un disLrito escolar puede permiLir acceso a los expedientes del alumno a
cualquier persona a Ja cual el padre del alumno ha ejecutado un consenLimiento por escrito especificando los expedientes que se van a
proporcionar e identificando al grupo 0 a la clasificaci6n del grupo al cual se Ie van a proporcionar los expedientes. Quien los recibe debe
ser notificado/a que la Lransmisi6n de I a informaci6n a oLros sin la autorizaci6n por escriLo del padre del alumno es prohibida. La hoja de
consentimiento debe eSLar permanentemente guardada con el expedienLe .