FCA 2024-2025 Medical & Emergency Notification

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Medical and emergency notification information. Please complete a separate form for each child.

Email *

Child Last Name *

Child First Name *

Child Date of Birth (mm/dd/yy) *

Child grade in the 2024-2025 academic year *

List all allergies and/or significant medical history *

Parent/Guardian #1 - Last Name *

Parent/Guardian #1 - First Name *

Parent/Guardian #1 Home Phone (if no home phone please indicate n/a) *

Parent/Guardian #1 Cell Phone (if no cell phone please indicate n/a) *

Parent/Guardian #1 Work Phone (if no work phone please indicate n/a) *

Parent/Guardian #2 - Last Name

Parent/Guardian #2 - First Name

Parent/Guardian #2 Home Phone (if no home phone please indicate n/a)

Parent/Guardian #2 Cell Phone (if no cell phone please indicate n/a)

Parent/Guardian #2 Work Phone (if no work phone please indicate n/a)

Name of Child's Physician *

Physician's phone # *

Physician's Address *

Medical Insurance Provider *

Policy/Insurance # *

EMERGENCY CONTACTS IN CASE PARENT/GUARDIAN CANNOT BE REACHED

Emergency Contact #1 - Last Name *

Emergency Contact #1 - First Name *

Emergency Contact #1 - relationship to student (grandparent, aunt, uncle, friend, etc.) *

Emergency Contact #1 - primary phone number *

Emergency Contact #1 - primary phone type *

Home

Cell

Work

Other:

Emergency Contact #1 - secondary phone number

Emergency Contact #1 - secondary phone type

Home

Cell

Work

Other:

Clear selection

Emergency Contact #2 - Last Name

Emergency Contact #2 - First Name

Emergency Contact #2 - relationship to student (grandparent, aunt, uncle, friend, etc.)

Emergency Contact #2 - primary phone number

Emergency Contact #2 - primary phone type

Home

Cell

Work

Other:

Clear selection

Emergency Contact #2 - secondary phone number

Emergency Contact #2 - secondary phone type

Home

Cell

Work

Other:

Clear selection

THIS FORM SHALL ACCOMPANY STUDENTS ON FIELD TRIPS. IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO UPDATE EMERGENCY INFORMATION AS NECESSARY.

A copy of your responses will be emailed to the address you provided.

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