EMERGENCY CONTACT CARD
2021 - 2022 SCHOOL YEAR
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Email *
First Name *
Last Name *
Class *
Student Cell Phone Number *
DATE OF BIRTH *
MM
/
DD
/
YYYY
I.D. NUMBER *
NAME OF PARENT STUDENT RESIDES WITH: *
PARENT'S PREFERRED LANGUAGE OF COMMUNICATION -- Written and Oral *
HOME PHONE NUMBER: *
PARENT CELL NUMBER *
PARENT WORK NUMBER *
PARENT EMAIL ADDRESS *
ADDRESS - INCLUDE APT., BOROUGH, ZIP CODE *
OTHER PARENT/GUARDIAN *
PARENT'S PREFERRED LANGUAGE OF COMMUNICATION -- Written and Oral *
ADDRESS - INCLUDE APT., BOROUGH, ZIP CODE *
LIST BELOW THE NAME OF A PERSON WHO MAY BE CALLED IN CASE OF EMERGENCY OR IF CHILD IS SICK IN SCHOOL. CHILD WILL BE REALEASED ONLY TO PERSON NAMED ON THIS CARD. Make sure to provide name and phone number. *
LIST BELOW THE NAME OF A PERSON WHO MAY BE CALLED IN CASE OF EMERGENCY OR IF CHILD IS SICK IN SCHOOL. CHILD WILL BE REALEASED ONLY TO PERSONS NAMED ON THIS CARD. Make sure to provide name and phone number. *
LIST BELOW THE NAME OF A PERSON WHO MAY BE CALLED IN CASE OF EMERGENCY OR IF CHILD IS SICK IN SCHOOL. CHILD WILL BE REALEASED ONLY TO PERSON NAMED ON THIS CARD. Make sure to provide name and phone number. *
IF THERE IS A PERSON WHO MAY NOT HAVE ACCESS TO CHILD, PLEASE INDICATE NAME AND RELATIONSHIP. ALSO INDICATE IF THERE IS AN ORDER OF PROTECTION. *
PRINCIPAL WILL BE NOTIFIED IN WRITING OF ANY CHANGES TO INFORMATION ON THIS CARD *
HEALTH INFORMATION: Provide name and phone of child's physician: *
HEALTH ALERT -- Does child have any health condition that may affect participation in physical activities? *
LIST YOUR CHILD'S ALLERGIES, IF ANY:
504 SERVICES FOR THE CURRENT YEAR *
MY CHILD HAS (X any that apply): *
Required
If none of the named contact can be reached, what do you wish the school to do if your child is sick or injured? It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible. *
SIBLINGS: Name and school of attendance *
SIBLINGS: Name and school of attendance *
SIBLINGS: Name and school of attendance *
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