St. Teresa School Emergency Form 2019-2020
Please complete all required information and hit submit. If you have more than one child please complete the additional student questions to avoid having to fill out a new form for each student.
Student First Name *
Your answer
Student Last Name *
Your answer
Student Grade for 2019-2020 School Year *
Additional Student #1 Full Name
Your answer
Additional Student #1 Grade 19-20 School Year
Additional Student #2 Full Name
Your answer
Additional Student # 2 Grade 19-20 School Year
Additional Student #3 Full Name
Your answer
Additional Student # 3 Grade 19-20 School Year
Student Street Address *
Your answer
City *
Your answer
State *
Your answer
Mother Full Name *
Your answer
Mother Cell # *
Your answer
Mother Work #:
Your answer
Father Full Name *
Your answer
Father Cell #
Your answer
Father Work #
Your answer
Legal Guardian (if different than above)
Your answer
Person to call in an emergency *
Your answer
Phone number *
Your answer
Person to be contacted if above person cannot be reached #1 *
Your answer
Phone number #1 *
Your answer
Person to be contacted if above person cannot be reached #2 *
Your answer
Phone number #2
Your answer
Person to be contacted if above person cannot be reached #3
Your answer
Phone number #3
Your answer
Does your child have a health problem the school should be aware of?
Your answer
In case of accident or serious illness, I request the school contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow the physician’s instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary. Physician’s Name: *
Your answer
Physician's phone number *
Your answer
Student lives with *
We would also appreciate your providing the following information which must be reported yearly to the National Catholic Education Association:
The Primary Contact Number will be used to call you every time we send a School Messenger call, regardless of the urgency of the message. Primary Contact Number: *
Your answer
The Secondary Contact Number will be called at the same time as the Primary Number on calls where the message we are sending is more of an urgent or time sensitive nature to ensure that we get the call to you as soon as possible. Secondary Contact Number:
Your answer
Primary Email Address *
Your answer
Secondary Email Address
Your answer
Person(s) authorized to pick up student from school and relationship to student #1: *
Your answer
Person(s) authorized to pick up student from school phone number #1: *
Your answer
Person(s) authorized to pick up student from school and relationship to student #2: *
Your answer
Person(s) authorized to pick up student from school phone number #2: *
Your answer
Person(s) authorized to pick up student from school and relationship to student #3:
Your answer
Person(s) authorized to pick up student from school phone number student #3:
Your answer
Any other important information
Your answer
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