Columbus City Schools Emergency Information Card
Yellow Emergency Card
Email address *
Student Name *
Last Name, First Name MI
Homeroom *
Date of Birth *
(Example: 01/01/2010)
Student's Home Primary *
(Example: 2744 W. Broad St., Columbus, Ohio 43204)
Child Lives With (select one) *
Parents are (select one) *
Please select relationship to student *
Full Name *
Contact Number *
(Example: 614-365-5964)
Email *
Employer Information *
(Name, Number & Address)
If your address is not the same as student, please list address below: *
Please select relationship to student *
Full Name *
Contact Number *
(Example: 614-365-5964)
Email *
Employer Information *
(Name, Number & Address)
If your address is not the same as student, please list address below: *
Emergency Contact #1 *
(Name, Relationship & Contact Number)
Emergency Contact #2 *
(Name, Relationship & Contact Number)
Emergency Contact #3 *
(Name, Relationship & Contact Number)
Emergency Contact #4 *
(Name, Relationship & Contact Number)
Today's Date *
MM
/
DD
/
YYYY
Parent Signature *
Type Full Name
A copy of your responses will be emailed to the address you provided.
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