Emergency Information Form 2021-2022
Brentwood Union School District
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Student Name (Last, First, Middle) *
Grade Level *
Sex *
Home Phone/Unlisted Number *
Date of Birth *
MM
/
DD
/
YYYY
Birthplace *
Home Address (Number, Street, City, Zip Code) *
INFORMATION REGARDING PARENT/GUARDIAN RESIDING WITH STUDENT
Name Mother/Stepmother/Guardian residing with student
Relationship to Student
Clear selection
Phone/Cell Number
Email Address
Place of Employment
Work Phone
Name Father/Stepfather/Guardian residing with student
Relationship to Student
Clear selection
Phone/Cell Number
Email Address
Place of Employment
Work Phone
Name of other parent/guardian with custody but NOT residing in home with child
Phone Number
Home Address (Number, Street, City, State, Zip Code)
Email Address
BOTH NATURAL PARENTS WILL HAVE CUSTODY OF THIS CHILD UNLESS THERE IS A CALIFORNIA COURT ORDER TO THE CONTRARY. BOTH NATURAL PARENTS RETAIN FULL ACCESS RIGHTS TO SCHOOL RECORDS AND REPORTS UNLESS OTHERWISE RESTRICTED BY A SPECIFIC COURT ORDER *
Required
Child Care *
Name of Child Care Provider
Address of Child Care Provider
Phone Number of Child Care Provider
IN CASE OF EMERGENCY, YOUR CHILD CANNOT BE RELEASED TO ANYONE OTHER THAN THOSE LISTED ON THIS FORM.
List below three persons (at least 18 years or older) that can be contacted in case of emergency, when parent/guardian cannot be reached. Note: if a student is to be picked up early (before end of school day) by anyone other than parent/guardian, advance notice must be given to office or student will not be released.
1st Emergency Contact Name *
1st Emergency Contact Relationship to Student *
1st Emergency Contact Phone Number *
2nd Emergency Contact Name *
2nd Emergency Contact Relationship to Student *
2nd Emergency Contact Phone Number *
3rd Emergency Contact Name *
3rd Emergency Contact Relationship to Student *
3rd Emergency Contact Phone Number *
Health/Insurance Plan and Plan Number *
HEALTH ALERT: Does your child have any special health problems (heart condition, epilepsy, diabetes, bee stings, allergies, etc.)? *
If yes, please explain
Other Alert:
Is your child regularly receiving medication? *
Name of Medication, Current Dosage, Supervising Physician, Physician Phone Number
IN CASE OF EMERGENCY
In case of emergency due to illness or injury, when no authorized persons can be reached, I give permission to Brentwood Union School District Personnel to obtain any necessary medical or dental attention for my child (NOTE: Parents(s)/Guardian(s) is/are responsible for all medical costs related to injury or accident). These instructions will remain in force until changed or revoked by the parent/guardian.
Parent/Guardian in home must sign and date below. *
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