Fort Hamilton High School Emergency Contact Card
Please use this form to update your child's emergency contact information for Fort Hamilton High School. A representative from the school will contact you to verify the information.
Student Information
Last Name: *
Your answer
First Name: *
Your answer
Middle Name:
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Sex: *
Your answer
Student's ID: *
Your answer
Parent/Guardian Information:
Parent/Guardian (Student resides with): *
Your answer
Relationship *
Your answer
Parent/ Guardian's Preferred Language of communication: *
Your answer
Written: *
Your answer
Oral: *
Your answer
Home Telephone: *
Your answer
Work Telephone:
Your answer
Cell No.: *
Your answer
E-mail
Your answer
Address: *
Your answer
Apt.
Your answer
City *
Your answer
State: *
Your answer
Zip: *
Your answer
Other Parent/Guardian:
Your answer
Relationship to student:
Your answer
Second Parent/Guardian's Preferred Language of Communication:
Your answer
Second Parent's Home Telephone:
Your answer
Second Cell No.:
Your answer
Second E-mail:
Your answer
Second Address:
Your answer
Second Apt:
Your answer
Second City:
Your answer
Second State:
Your answer
Second Zip:
Your answer
List three (3) persons who may be called in case of emergency or if child is sick in school.
CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD.
Name #1: *
Your answer
Phone Number #1: *
Your answer
Relationship #1: *
Your answer
Name #2:
Your answer
Phone Number #2:
Your answer
Relationship #2:
Your answer
Name #3:
Your answer
Phone Number #3:
Your answer
Relationship #3:
Your answer
If there is a person who may NOT HAVE ACCESS to child. please indicate:
No Access Name:
Your answer
Relationship to student:
Your answer
Order of Protection Exists?
HEALTH INFORMATION
Name of Physician/Clinic: *
Your answer
Telephone: *
Your answer
Does your child have any health conditions that may affect participation in physical activities? *
Limitations (e.g. , stair climbing, participation in gym) :
Your answer
Allergies:
Your answer
504 services for the current year? *
My child has: *
If "No Health Insurance," are you willing to share contact information from this card to learn about insurance options?
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.
Your answer
Does your child have any siblings?
List sibling's full name and school of attendance.
1. Sibling Name:
Your answer
1. School of Attendance:
Your answer
2. Sibling Name:
Your answer
2. School of Attendance:
Your answer
3. Sibling Name:
Your answer
3. School of Attendance:
Your answer
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