California Middle School Digital Emergency Contact Information Form
Email address *
Student Last Name *
Student First Name *
Student Middle Name
Date of Birth *
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Street Address, Including Apt# if applicable. *
Zip Code *
Parent/Guardian #1 Last Name *
Parent/Guardian #1 First Name *
Parent/Guardian #1 Street Address *
Parent/Guardian #1 City *
Parent/Guardian #1 Zip Code *
Parent/Guardian #1 Cell Phone *
Parent/Guardian #1 Home Phone *
Parent/Guardian #1 Work Phone
Parent/Guardian #1 Email Address
The school PTA may have my email address
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Parent/Guardian #1 Place of Work Address
Parent/Guardian #2 Last Name
Parent/Guardian #2 First Name
Parent/Guardian #2 Street Address
Parent/Guardian #2 City *
Parent/Guardian #2 Zip Code
Parent/Guardian #2 Cell Phone
Parent/Guardian #2 Home Phone
Parent/Guardian #2 Work Phone
Parent/Guardian #2 Email Address
The school PTA may have my email address
Clear selection
Parent/Guardian #2 Place of Work Address
List names of other children attending this school:
Parent/Guardian(s) with whom the child lives *
If parents are divorced or separated, to whom has physical custody been given? (verification can be emailed to savannah-zanze@scusd.edu if not already on file with the school)
The adults listed below are authorized to pick up and care for the above named student. ADULT #1
ADULT #1 Phone Number
ADULT #1 Relationship
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ADULT #2 Name
ADULT #2 Phone Number
ADULT #2 Relationship
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ADULT #3 Name
ADULT #3 Phone Number
ADULT #3 Relationship
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ADULT #4 Name
ADULT #4 Phone Number
ADULT #4 Relationship
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ADULT #5 Name
ADULT #5 Phone Number
ADULT #5 Relationship
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1. General Health Information, Click below if there are NO health problems, can skip to item #10.
2. General Health Information, Click below if there ARE health problems
3. Does the student wear glasses or contact lenses?
4. Does the student wear hearing aids or is the student diagnosed with hearing loss?
5. Please check all that apply to your child
6. Please describe any other health problems, or expand on above listed health problems as appropriate.
7. List all medication, with dose, taken by your child and indicate if taken at home and/or at school.
8. Does the student have a condition that limits participation in the classroom or physical education? If so, please explain. (NOTE: The physician must provide a note explaining the limitation and reason for the the student's limited participation in physical education and the note must be updated every school year.)
9. Special Instructions/Comments: List any special health needs or medical problems, including specific allergic reactions (food, bee sting, etc.), if student has an active emergency care plan, medical 504 plan, Diabetic Medical Management Plan, etc.
10. Emergency Authorization: In the event of an emergency, when a parent/guardian is unavailable, I authorize school personnel to make such arrangements for my child to receive medical/hospital care, including necessary transportation, in accordance with their best judgement. I further authorize the physician names below to undertake such care of my child, as he/she/they consider necessary. In the event said physician is not available, I authorize such care and treatment to be performed by licensed physician or surgeon. I understand that the parent or guardian is responsible for the cost of such emergency care. *
Required
11. Physician Name
12. Physician Phone
13. Preferred Emergency Facility/Phone
14. Does this student have health insurance
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15. Name of Insurance Plan Provider
16. If not, I give permission for SCUSD to share this information to help apply for health insurance for my child.
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17. Does this student have dental insurance?
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Please Read
18. I certify that this information is true and correct by typing my full name below: *
19. Date completed *
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A copy of your responses will be emailed to the address you provided.
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