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Student Emergency Information
Student Emergency Information Card
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* Indicates required question
Homeroom Teacher
*
Ms. Lin
Mr. Gillett
Student Class Number
On their pencil box on their desk
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Student Email
*
From AEA
Your answer
Student Email Password
Just incase they forgot
Your answer
Address
*
House Number, Street Name
Your answer
Apt #
Apartment number
Your answer
City
*
Your answer
Zip Code
*
Your answer
Who should we call first?
*
If not Father or Mother, please enter relationship and number
Mother
Father
Other:
Required
Mother's Full Name
*
First Name and Last Name
Your answer
Mother's E-Mail
To send you information about your child
Your answer
Mother's Cell Number
*
With area code please
Your answer
Mother's Home Number
*
With area code please
Your answer
Mother's Work Number
With Work Ext.
Your answer
Mother's Work/Company Name
Your answer
Live with?
*
Yes
No
Other:
Required
Father's Full Name
*
First Name and Last Name
Your answer
Father's Email
To send you information about your child
Your answer
Father's Cell Number
*
With area code please
Your answer
Father's Home Number
*
With area code please
Your answer
Father's Work Number
With Work Ext.
Your answer
Father's Work/Company Name
Your answer
Live with?
*
Yes
No
Other:
Required
Other (Step-Parent/guardian)
First Name and Last Name
Your answer
Relationship with Child
ie:Step-Parent/Guardian
Your answer
Other Contact's Cell Number
With area code please
Your answer
Other Contact's Home Number
With area code please
Your answer
Other Contact's Work Number
With area code please
Your answer
Live with?
Yes
No
Other:
Emergency Contact
*
First and Last Name of the person(s) to call IF PARENT OR GUARDIAN CAN NOT BE REACHED. These emergency contacts must live locally, have a telephone and be willing to provide transportation.
Your answer
Emergency Contact's Cell Number
*
With area code please
Your answer
Emergency Contact's Home Number
*
With area code please
Your answer
Does student have any health problems or allergies that might require special attention while at school?
*
Y/N. If Yes, please explain and be specific
Your answer
Does student have a hearing or vision problem?
*
Y/N. If Yes, please explain and be specific
Your answer
Is student on a continuing medication?
*
Y/N. If Yes, what medication? **If the student needs medication at school, the doctor and parents must complete form #440 available in the office.
Your answer
Do you give permission to have your student's picture, likeness, or words included in School publications or media materials?
*
ie. School Newspaper, Class Newsletter, Weekly Letters, Class Website(s) and/or etc.
Yes
No
Other:
Do you give permission to have your student's work published?
*
ie. School Office, School Newspaper, Class Newsletter, Weekly Letters, Class Website(s) and/or etc.
Yes
No
Other:
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