Emergency Information Card
Please fill out this form for every child. Please add "NA" if any question does not apply.
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Students Enrolled Building *
Students First Name *
Students Last Name *
Student Bus Number(s) *
Grade *
Student Homeroom *
Students Birthday *
MM
/
DD
/
YYYY
Students Home Address *
Students Home Phone Number *
Mothers First Name *
Mothers Last Name *
Mothers Work Number *
Mothers Cell Phone Number *
Mothers Email Address *
Fathers First Name *
Fathers Last Name *
Fathers Work Number *
Fathers Cell Phone Number *
Fathers Email Address *
List at least two persons who will assume temporary care of your child if you cannot be reached. (Person should be able to supply transportation for child.):
Emergency Contact 1 First Name *
Emergency Contact 1 Last Name *
Emergency Contact 1 Relationship *
Emergency Contact 1 Home Phone Number *
Emergency Contact 1 Cell Phone Number *
Emergency Contact 2 First Name *
Emergency Contact 2 Last Name *
Emergency Contact 2 Relationship *
Emergency Contact 2 Home Phone Number *
Emergency Contact 2 Cell Phone Number *
Who does the child reside with?  (If other, please add name and phone number) *
Do parents have joint custody? (Please type Yes, No or who has custody.) *
Parent Address if different from above. Please indicate if this is the Mother or the Fathers address. *
It is absolutely necessary that the school be informed of any conditions such as: seizures, diabetes, asthma, heart ailments, hearing problems, nosebleeds, etc. (Give treatment information also) Please list: *
Physicians Name *
Physicians phone number *
Is you child covered by Health Insurance? *
My child is on daily medication for: *
Name of medication(s): *
Is the medication(s) required during school hours *
The school physician/dentist has my permission to do the required health examinations/screenings if the appropriate forms have not been completed by my private physician/dentist and returned to the nurse. If not indicated the school physician/dentist will complete exam. *
Since the care and treatment of any child is primarily a parental responsibility, by checking "Yes" below I understand that every effort will be made to contact either parent first in case your child becomes ill or is injured at school. In case of an emergency, your child will be transported to the nearest medical facility. *
Required
By checking "Yes" below, I give permission to share this information with appropriate school/medical personnel: *
Required
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