JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Emergency Contact Card
This is the Emergency Contact Form for School Year 2020 - 2021.
To begin, enter your child's Last, and First name.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Middle Initial:
Your answer
Date Of Birth:
*
MM
/
DD
/
YYYY
Sex:
*
Female
Male
Student ID#
*
Your answer
Parent/Guardian's Name:
*
Your answer
Relationship:
*
Your answer
Parent's Preferred Written Language of Communication:
*
Your answer
Parent's Preferred Spoken Language of Communication:
*
Your answer
Home Telephone:
Your answer
Work Telephone:
Your answer
Cellphone Number:
Your answer
E-Mail Address:
*
Your answer
Address
*
Your answer
Apt.
Your answer
Borough:
*
Your answer
ZIP Code
*
Your answer
Other Parent/Guardian:
Your answer
Other Parent/Guardian Relationship:
Your answer
Other Parent/Guardian's Preferred Written of Communication:
Your answer
Other Parent/Guardian's Preferred Spoken Language of Communication:
Your answer
Other Parent/Guardian's Home Telephone:
Your answer
Other Parent/Guardian's Work Telephone:
Your answer
Other Parent/Guardian's E-Mail Address:
Your answer
Other Parent/Guardian's Address:
Your answer
Other Parent/Guardian's Apt:
Your answer
Other Parent/Guardian's Borough:
Your answer
Other Parent/Guardian's ZIP Code:
Your answer
List below names of three (3) persons who may be called in case of emergency, or if child is sick in school. CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD.
Emergency Contact 1's Name:
*
Your answer
Emergency Contact 1's Phone:
*
Your answer
Emergency Contact 1's Relationship:
*
Your answer
Emergency Contact 2's Name:
*
Your answer
Emergency Contact 2's Phone:
*
Your answer
Emergency Contact 2's Relationship:
*
Your answer
Emergency Contact 3's Name:
*
Your answer
Emergency Contact 3's Phone:
*
Your answer
Emergency Contact 3's Relationship:
*
Your answer
If there is a person who may NOT HAVE ACCESS to child, please indicate:
Name:
Your answer
Relationship:
Your answer
Order of Protection Exists?
Your answer
Principal will be notified in writing of any changes to information on this card: (Print name for Electronic Signature)
*
Your answer
Grade:
Your answer
Class:
Your answer
Room No.
Your answer
Teacher:
Your answer
Health Information
Name of Physician/Clinic
Your answer
Telephone
Your answer
Health Alert
Does child have any health condition that may affect participation in physical activities?
*
Yes
No
Limitations
Your answer
Allergies
Your answer
504 services for the current year?
*
Yes
No
Previous year?
*
Yes
No
My child has:
Private Health Insurance
Medicaid
No Health Insurance
Clear selection
If "No Health Insurance" are you willing to share contact information form this card to learn about insurance:
Yes
No
Clear selection
If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?
Your answer
It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.
Does the child have any siblings? (If not, you may skip the following questions.)
Sibling 1's Last Name:
Your answer
Sibling 1's First Name:
Your answer
Sibling 1's School of Attendance:
Your answer
Sibling 2's Last Name:
Your answer
Sibling 2's First Name:
Your answer
Sibling 2's School of Attendance:
Your answer
Sibling 3's Last Name:
Your answer
Sibling 3's First Name:
Your answer
Sibling 3's School of Attendance:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Brooklyn School of Inquiry.
Report Abuse
Forms
