Emergency Information
Email address *
Activity *
Student First Name (Please capitalize the first letter with the rest lower case i.e. John) *
Your answer
Student Last Name (Please capitalize the first letter with the rest lower case i.e. Smith) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Primary Guardian Name *
Your answer
Primary Guardian Work Phone Number
Your answer
Primary Guardian Cell Phone Number *
Your answer
Secondary Guardian Name (if applicable)
Your answer
Secondary Guardian Work Phone Number
Your answer
Secondary Guardian Cell Phone Number
Your answer
Emergency Contact Name (In the event we can't get a hold of a guardian) *
Your answer
Emergency Contact Relation *
Your answer
Emergency Contact Phone Number *
Your answer
Insurance Name *
Your answer
Insurance Policy Number *
Your answer
Preferred Hospital *
Your answer
Would you allow for your student to be transported in an ambulance? *
List any medication(s) your student uses
Your answer
List any allergies your student may have.
Your answer
Please provide information about your students medical condition(s) if applicable.
Your answer
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