BLUE CARD
INFORMATION COLLECTED FOR THE DOE EMERGENCY CONTACT CARD
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Student LAST name *
Student FIRST name *
STUDENT DATE OF BIRTH *
MM
/
DD
/
YYYY
STUDENT CELL PHONE NUMBER *
PARENT/GUARDIAN NAME (Primary/students lives with) *
Relationship *
PARENT/GUARDIAN Preferred language of Communication *
Required
Parent/Guardian CELL PHONE# *
Parent/Guardian EMAIL address *
Primary Guardian Home address (with apt#) *
Borough *
Required
Parent/Guardian CELL PHONE# *
zipcode *
HEALTH ALERT & LIMITATIONS Please describe any health condition that we need to be aware of including any that may affect participation in physical activities or limit mobility. *
ALLERGIES
Name  & Contact # of Physician *
Other Guardian
Relationship
Parent/Guardian EMAIL address
Is there  anyone who may NOT HAVE ACCESS to student?
Please list 3 persons (names & numbers) we may try to contact if we can not reach you. *
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