Columbus City Schools Emergency Information Card
Yellow Emergency Card
* Required
Email address
*
Your email
Student Name
*
Last Name, First Name MI
Your answer
Homeroom
*
Your answer
Date of Birth
*
(Example: 01/01/2010)
Your answer
Student's Home Primary
*
(Example: 2744 W. Broad St., Columbus, Ohio 43204)
Your answer
Child Lives With (select one)
*
Both Parents
Mother Only
Father Only
Foster Parent(s)
Other Guardian
Parents are (select one)
*
Married
Divorced
Single-never married, not residing together
Residing together-not married
Please select relationship to student
*
Mother
Stepmother
Guardian
Foster Mother
Full Name
*
Your answer
Contact Number
*
(Example: 614-365-5964)
Your answer
Email
*
Your answer
Employer Information
*
(Name, Number & Address)
Your answer
If your address is not the same as student, please list address below:
*
Your answer
Please select relationship to student
*
Father
Stepfather
Guardian
Foster Father
Full Name
*
Your answer
Contact Number
*
(Example: 614-365-5964)
Your answer
Email
*
Your answer
Employer Information
*
(Name, Number & Address)
Your answer
If your address is not the same as student, please list address below:
*
Your answer
Emergency Contact #1
*
(Name, Relationship & Contact Number)
Your answer
Emergency Contact #2
*
(Name, Relationship & Contact Number)
Your answer
Emergency Contact #3
*
(Name, Relationship & Contact Number)
Your answer
Emergency Contact #4
*
(Name, Relationship & Contact Number)
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Parent Signature
*
Type Full Name
Your answer
A copy of your responses will be emailed to the address you provided.
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