Emergency Facility Form
Christus Spohn Hospital-Beeville
(unless other hospital is specified)
Official Form February 23, 2005

Please list any special medical information that may affect your child:

Allergies: ______________________________________________________________________________

Medications for long term use: _____________________________________________________________

Surgeries/major medical procedures: ________________________________________________________

History of major illnesses or injury: __________________________________________________________

    *Has your child had chicken pox? __________If yes, please give approximate month & year ________

    *Has your child had the Chicken Pox Immunization? __________________________________

    *Last TB Test given (date) ___________________________Results ______________________

I acknowledge that my child's immunizations are current and on file at First Baptist Church School, 600 N. St. Mary's, Beeville

            ___________________________________________________  __________________________
            Parent or Legal Guardian Signature                                        Date

In the event of an emergency when medical attention is required, I give my permission to the staff or sponsor of First Baptist Church
 School to obtain the services of a licensed physician for any necessary treatment for my child. Please attempt to notify me
 immediately concerning any such emergency.

            ___________________________________________________  ____________________________
            Parent or Legal Guardian Signature                                        Date

In case of an emergency in which the parents cannot be reached, please call: (we must have two)

(1) _______________________________________________________________________________________
    Name                                    Relationship to child                Hm Phone                        Wk Phone

(2) _______________________________________________________________________________________
    Name                                    Relationship to child                Hm Phone                        Wk Phone

In the event a parent cannot pick up the child after school, the persons listed below are authorized to do so. Please give names
 of others who are authorized to pick up your child from school other than the 2 listed above.

Name ________________________________________ Phone______________________________________

Name ________________________________________ Phone______________________________________

Name ________________________________________ Phone______________________________________