Emergency Contact Form
Student Last Name *
Your answer
Student First Name *
Your answer
Current Grade Level (2017-2018 school year) *
Current School (2017-2018 school year) *
Student is enrolling in: *
Required
Student Address *
Your answer
Parent/Guardian 1 Name
Your answer
Parent/Guardian 1 Phone #
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 Phone #
Your answer
Are there any special circumstances concerning child custody issues? *
If Yes, please explain/provide a copy of any legal documents prohibiting release of your child to any individual(s) to your child's teacher
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone # *
Your answer
Does your child have any medical condition or history that affects their ability to participate in this program? *
If yes, please briefly explain
Your answer
Does your child require any medication? *
If yes, what is the name of the medication and reason for requiring it?
Your answer
Is the student allergic to any of the following?
If you checked any of the above allergens, please explain/describe the reaction/required treatment
Your answer
Does the student require medication to be with them while attending this program? *
If yes, please bring the doctors’ orders to the Nurse on the first day of Summer Music.
By checking this box, a parent/guardian attests that the above information is correct and gives permission for the information to be shared with the appropriate staff (as needed) *
Required
Name of parent/guardian completing this form? *
Your answer
Thank you for filling out the Emergency Contact form!
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