2026 Player Emergency Card Information
Dear Parents or Guardians:

One of the most important responsibilities we have as parents, students, and district employees is being Prepared in case of an emergency. 

Various types of emergencies may occur during the school day. A pupil may become ill or get injured at school, or a major earthquake may strike unexpectedly. By being prepared in advance, we can minimize injury and confusion.

We need your cooperation on a very important matter. During an emergency, we may need to reach you or a designated representative during school hours. This information must be on file at the school. To help us serve you, please complete the Emergency Information Cards and return them to your pupil's school.

Your cooperation is greatly appreciated. Thank you. 

Email *
 
Student Last Name:
 *
Student First Name: *
Home Phone Number: *
Grade in the Fall: *
Student Birthdate: *
MM
/
DD
/
YYYY
Home Language: *
Home Address: *
Parent 1/Last Name:  *
Parent 1/ First Name:  *
Parent 1/Email:  *
Parent 1/Cell Phone: *
Parent 1/ Email: *
Parent 2/  Last Name: *
Parent 2/First Name: *
Parent 2/ Email: *
Parent 2/ Cell Number: *
IN CASE YOU ARE UNABLE TO REACH ME DURING AN EMERGENCY, YOU ARE AUTHORIZED TO CONTACT AND, IF NECESSARY, RELEASE MY CHILD TO ANY OF THE FOLLOWING:
Emergency Contact Name:  *
Emergency Contact Cell Number: *
Emergency Contact Relationship: *
DOES YOUR CHILD HAVE ANY SIBLINGS ATTENDING PALISADES CHARTER HIGH SCHOOL:
Sibling First Name, Last Name, Grade Level *
IN A MAJOR EMERGENCY, IT IS THE SCHOOL'S POLICY TO RETAIN STUDENTS AT SCHOOL FOR THEIR SAFETY. THE INFORMATION ON THIS FORM WILL BE USED BY SCHOOL STAFF TO RELEASE STUDENTS.
Parent 1 Signature (Please Print Your Name): *
Parent 2 Signtature (Please Print Your Name): *
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT:
The undersigned, legal custodian of the minor student, hereby authorizes the principal or designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any licensed physician and/or dentist. 

It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary.

This authorization is given provisions of Section 25.8 of the California Civil Code, and shall remain effective for the full school year unless revoked in writing and delivered to said agent(s). I understand that Palisades Charter High School, its officers and its employees assume no liability of any nature in relation to the transportation of the said minor. I further understand that all costs of paramedic transportation,hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be borne by the undersigned. 
Doctor: *
Daytime Phone Number: *
Insurance Plan  *
Group or Policy Number: *
My child is allergic to the following: *
Other medications used:
If none, enter N/A
 *
Sigature of parent or guardian (Print Name): *
A copy of your responses will be emailed to .
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