PTG Emergency Form
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Email *
Parental Instructions In Case of Emergency and Medical Information
Please complete this form as fully as possible.
Student Name *
(Last, First, Middle)
Student ID *
Date of Birth *
Counselor *
Grade *
Year of Graduation *
Address
Zip Code
Home Phone
Student's Mobile Phone
Student's Email Address
Parent's Email address
Emergency Contacts
Please list everyone we can call in case of an emergency, illness, school closing, or other issue requiring notification.  Please note: if a parent/guardian is not available we will call the next person on the list until someone is contacted.
Contact 1 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Contact 2 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Contact 3 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Contact 4 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
This information will be shared with appropriate school staff.
If the designated parties on this card are not available, I understand  appropriate emergency care deemed advisable by school authorities will be sought. Any special directions appropriate to my child have been checked and noted on this form.

Doctor's Name and Phone #
Dentist's Name and Phone #
Hospital for Emergency
Emergency Clinic
Very Important - please indicate if any of the below apply to your child.
Add specifics where indicated.
Religious Objections to Physician Contact
Food Restrictions
Contact Lenses/Glasses
Bone/Joint Condition
Diabetes
Heart Condtion
Seizure Disorder
Hypertension / High Blood Pressure
Asthma
Special Blood Condition
Life-threatening Allergies
Medications Needed or Used
List below
Other Conditions or Problems
List below
No Medical Conditions known
Parent/Guardian Signature
Indicate the Parent/Guardian filling out this form.
Date filled out
Submit
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This form was created inside of Ann Arbor Public Schools.

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