Emergency Contact and Medical Information
Student Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity/Race *
Gender *
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
Email Address
Your answer
Parent/Guardian Name #2
Your answer
Phone Number #2
Your answer
Address #2
Your answer
Email Address #2
Your answer
Alternative Emergency Contact #1 (Name, Phone Number, Relationship)
Your answer
Alternative Emergency Contact #2 (Name, Phone Number, Relationship)
Your answer
Adults Authorized to Pick Up Child (Name and Phone Number)
Your answer
Physician Information (Name and Phone Number)
Your answer
Hospital/Clinic Preference
Your answer
Allergies/Special Health Considerations
Your answer
Regular Medications, Treatments or Medical Care
Your answer
Parent's/Guardian's Signature and Date
Your answer
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