Emergency Form
PLEASE PROVIDE THE FOLLOWING INFORMATION TO BE USED IN CASE OF ILLNESS OR EMERGENCY.
(This form needs to be completed on each student and returned to the school nurse during the first week of school.)
Year of Graduation *
Student Legal Full Name *
Your answer
Goes By
Your answer
Living With: (Name) *
Your answer
Relationship *
Your answer
Home Address *
Your answer
Home Phone *
Your answer
Student Cell Phone
Your answer
Cellular Phone Numbers: (Mother) *
Your answer
Cellular Phone Number: (Father) *
Your answer
Emergency Contact and Student Release
Alternate persons to be notified if parents cannot be reached: (Local relative, friend or neighbor)
1st Emergency Contact (Name and Phone) *
Your answer
2nd Emergency Contact (Name and Phone) *
Your answer
Physician (Name and Phone) *
Your answer
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