Emergency Medical Information and Release


    Each year our school updates emergency information for all students.  Please complete the questionnaire below for the students in your household and return it to the School Nurse on or before the first day of school.   Since the medical information being provided may be different for each child it is necessary that a separate form be used for each child.  This form will be availble for field trips during the school year. 

    **** Please  Note: Parental Guardian signature is required to place this information into cattaraugus Little Valley District Power School****


    Legal Name of Student                                          Date of Birth                   Grade/Teacher

    _________________________________              ___________                              _____


    Parent(s) or Guardian: ___________________________________________________

    Street Address: _________________________________________________________

                             Home Phone                                               Cell Phone                          _


    Father’s Place of Work:__________________________________________________

    Work Phone Number ____________________________________________________


    Mother’s Place of Work: _________________________________________________

    Work Phone Number ____________________________________________________


    Persons to notify in case of emergency (OTHER THAN LISTED ABOVE):


    Name _____________________________________________Phone (___)__________

    Address _______________________________________________________________


    Name: ________________________________________________________________

    Address _______________________________________________________________


    Personal Physician:

    Name______________________________________________ Phone (___)________

    Address ______________________________________________________________



    Name______________________________________________ Phone (___)________

    Address ______________________________________________________________


    Health/Accident Insurance Company: _____________________________________

    Policy Number: __________________                                  (Please see reverse)                                                                        

    Primary/MS-HS Campus


    Intermediate Campus

    25 Franklin St. N


    207 Rock City St.

    Cattaraugus, NY 14719-1199


    Little Valley, NY 14755-1298

    High School:


    Phone: (716) 938-9155

    Phone: (716) 257-3483

    Phone: (716) 257-3436

    Fax:     (716) 938-6576

    Fax:     (716) 257-5108

    Fax:     (716) 257-5237




    Medical Information:  Additional information not listed on Health Record


    Allergies requiring Benadryl or Epi Pen:  ___ Yes          ___ No 
    If yes, please explain ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________





    Medications:________________________________ _________________________________________________________________________




    Authorization Consent for Medical Treatment of a Minor:

      I authorize the Cattaraugus-Little Valley Central School personnel to transfer, admit, and authorize any hospital or physician to  render treatment to my child or legal ward in the event of accident or illness.  I also give my permission for trained adult leaders to administer first aid without delay and /or seek professional medical treatment.  I expect every reasonable effort to be made to contact the parent, legal guardian and/or family physician.  In case of emergency, I give permission for a field trip leader to select physicians, secure proper treatment.




            (Parent/Guardian Signature)

















     Emergency Closing Information 



    If the school should close early due to weather or other related issues……my child/children ___________________________ are to follow these instructions: _________________________________________________________________________________________________________________________________________________________________________________


    Please list a daytime phone number where you or your childcare provider can be reached if there is an early dismissal.



     *** Recent changes to NYS Education Law requirtes that body mass index (BMI) and weight status groups be included as part of the students's school health examination in grades PreK or K, 2nd, 4th, 7th or 10th. We will be reporting our students' weight status groups. Our summary information is sent, no names and no information about individual students are sent. However, you may choose to have your child's information excluded from this survey report. If you do not wish to have your child included, you need to complete and sign a form stating this. Please contact any of the School Nurses for this form**