Emergency Contact Form

Student Information

Student Name*

First Middle Last

ID Number

Date of Birth

Sex

Female

Male

Prefer not to say

Other

Parent/ Guardian Information

Parent/ Guardian Name

First Last

Relationship

Preferred Language of Communication

Phone Number

Home Phone

Work Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Parent/ Guardian Email*

Other Parent/ Guardian Information

Parent/ Guardian Name

First Last

Relationship

Preferred language of communication

Phone Number

Home Phone

Work Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Parent/ Guardian Email

List three (3) persons who may be called in case of emergency if child is sick in school CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD

Emergency Contact #1

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship

Emergency Contact #2

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship

Emergency Contact #3

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship

If there is a person who may NOT HAVE ACCESS to the child, please indicate:

Name

First Last

Relationship

Order of protection exists?

Signature:*

Principal will be notified in writing of any changes to the information on this card.

Physician/ Clinic Name

First Last

Physician/ Clinician Phone

Health Conditions

Limitations

Allergies

504 services for the current year?

Previous year?

Medical Insurance

My child has:

Share Contact?

Are you willing to share contact information from this card to learn about insurance options?

Emergency Instructions

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?

It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.

Sibling Information

Sibling #1 Name

First Last

School of Attendance

Sibling #2 Name

First Last

School of Attendance