Student Emergency Form - Lunenburg Public Schools (2021-2022)
The Student Emergency Form is required each year to collect student health information and consent for emergency care. Please complete a new form each school year or as information changes. This year, we will utilize an online Student Emergency Form. A receipt will be automatically sent to the email address of the parent/guardian who submits the form. Please note that the form needs to be completed in one sitting (i.e. you cannot save and return to complete).
Email of parent/guardian submitting form *
A receipt will be automatically sent to this email address upon submission
Student's Last Name *
Student's First Name *
Student's Middle Name
Student's Street Address *
Student's City / Town *
Student's State *
Student's Zip Code *
Student's Home Telephone Number *
xxx xxx xxxx
Gender *
Date of Birth (mm/dd/yyyy) *
MM
/
DD
/
YYYY
Current School *
Current Grade Level *
Please indicate PreK through 12
Restraining / Custody Disputes? *
How does student travel TO SCHOOL? *
If student takes a bus TO school, which bus #?
How does student travel FROM SCHOOL? *
If student takes a bus FROM school, which bus #?
Student lives with (please check all that apply) *
Required
If other is chosen, please briefly describe living arrangement.
Siblings and school attended (if applicable)
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