Emergency Contact Form
Please help keep our data current by updating your student info - contacts, address, or phone number changes.
Student's Information
Please complete the following information about your student.
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Middle Name
Your answer
Gender *
Birthdate *
MM
/
DD
/
YYYY
Grade
Mailing Address - Primary
Enter the address of the student's primary residence.
Street, Apt/Suite *
Your answer
City *
Second Mailing Information
If you are divorced or separated and would like your child's information sent to this address in addition to the primary address, please complete the following.
Second Mailing Request *
Complete the following ONLY IF you want to receive a second mailing. If not, continue onto the next section.
Relationship to Student
Second Mailing Name (Last, First)
Your answer
Second Mailing Street, Apt/Suite
Your answer
Second Mailing City
Parent/Guardian Information
Mother's Name - Last, First *
Your answer
Mother's Home Phone *
Your answer
Mother's Work Phone
Your answer
Mother's Cell Phone
Your answer
Mother's Employer
Your answer
Father's Name - Last, First *
Your answer
Father's Home Phone *
Your answer
Father's Work Phone
Your answer
Father's Cell Phone
Your answer
Father's Employer
Your answer
E-mail is an important communication tool, please provide a current e-mail address that is often checked in your household.
Parent/Guardian Email Address
Your answer
Additional Parent Information - not required.
Ex. Step Mother, Step Father, Guardian
1. Name (Last, First)
Your answer
Relationship
Cell Phone
Your answer
Emergency & Health Information
The individuals below have authorization to pick up my child and can be reached during school hours at the number listed.
Emergency Contact #1
Please provide at least one point of contact.
Contact #1 Name (Last, First) *
Your answer
Contact #1 Relationship *
Contact #1 Phone Number *
Your answer
Emergency Contact #2
Contact #2 Name (Last, First)
Your answer
Contact #2 Relationship
Contact #2 Phone Number
Your answer
Emergency Contact #3
Contact #3 Name (Last, First)
Your answer
Contact #3 Relationship
Contact #3 Phone Number
Your answer
In case of serious accident or illness at school, your child will be sent to an emergency medical facility. The parent(s)/guardian(s) is responsible for all expenses.
Doctor's Name
Your answer
Doctor's Phone Number
Your answer
Allergies
Your answer
Special Medical Considerations
Your answer
Transportation Information
Please provide any transportation information you may know.
Bus Number
The bus number your student will be riding.
Your answer
Additional Transportation Information
Directions from school to your house.
Your answer
Signature - By printing your name this will be considered your Electronic Signature
Parent signature indicates approval to share health information with school staff (includes bus drivers) when necessary. **Your signature also grans permission for Braham Area Schools to use your child's image (photo) and or class work to be used in newspaper articles, yearbook, videos, or the school website to promote school events.
Your answer
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