PTG Emergency Form
Parental Instructions In Case of Emergency and Medical Information
Please complete this form as fully as possible.
Student Name *
(Last, First, Middle)
Your answer
Student ID *
Your answer
Date of Birth *
Your answer
Counselor *
Your answer
Grade *
Year of Graduation *
Your answer
Address
Your answer
Zip Code
Your answer
Home Phone
Your answer
Student's Mobile Phone
Your answer
Student's Email Address
Your answer
Parent's Email address
Your answer
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
Your answer
Contact 2 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Your answer
Contact 3 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Your answer
Contact 4 Name and Contact Information
Provide all applicable phone, mobile, and pager numbers
Your answer
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 #
Your answer
Dentist's Name and Phone #
Your answer
Hospital for Emergency
Your answer
Emergency Clinic
Your answer
Very Important - please indicate if any of the below apply to your child.
Add specifics where indicated.
Religous Objections to Physician Contact
Contact Lenses/Glasses
Bone/Joint Condition
Your answer
Diabetes
Heart Condtion
Your answer
Seizure Disorder
Hypertension / High Blood Pressure
Asthma
Special Blood Condition
Your answer
Life-threatening Allergies
Your answer
Medications Needed or Used
List below
Your answer
Other Conditions or Problems
List below
Your answer
No Medical Conditions known
Parent/Guardian Signature
Indicate the Parent/Guardian filling out this form.
Your answer
Date filled out
Your answer
Submit
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