Immaculate Conception PSR Family Emergency Information
Family Name
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Email Address
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Street Address
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City
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State
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Zip
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Parent Information
Father's Last Name
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Father's First Name
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Father's Occupation
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Father's Phone
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Father's Religion
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Father (Check all that apply)
Mother's Last Name
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Mother's First Name
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Mother's Occupation
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Mother's Phone
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Mother's Religion
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Mother (Check all that apply)
Child/Children lives with
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Phone
If different than above
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Please complete the following for each child:
Name, Grade, M/F, Birthdate (MM/DD/YY), City, State of Birth - please create a separate line for each child
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Please note any of the following conditions.
Type name and item: Has an IEP, Medication (list), Inhaler, Allergies, Other
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Emergency Information
Emergency Contact #1 Name
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Emergency Contact #1 Address
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Emergency Contact #1 Phone
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Emergency Contact #2 Name
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Emergency Contact #1 Address
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Emergency Contact #1 Phone
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In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hearby authorize the school to call 911 and make whaterver arrangements seem necessary.
Signature of Parent or Guardian
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Date
MM
/
DD
/
YYYY
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