PS 39 Emergency Contact and Health Information (Blue Card)
This emergency contact information is a vital communication tool for the school. Please be sure to fill in the form as completely as possible. This information is used by the main office, the nurse and the classroom teacher. Families will be required to fill out the form only ONCE for up to 3 children. For those families with more than three children, please complete the form for the oldest three and then do it again for the other children.

If the information that you provide on this Emergency Form should change during the school year, please contact the main office to update your card. You may also contact our Parent Coordinator, Karen Herskowitz at kherskowitz@ps39.org with any questions or needs.

First Student Information
Please enter information about the first child attending PS 39
1st Student Last Name *
Your answer
1st Student First Name *
Your answer
1st Student Middle Initial
Your answer
1st Student Date of Birth (MM/DD/YYYY) *
Your answer
1st Student Sex *
1st Student's Grade in 2019 - 2020 School Year *
Name of Physician/Clinic *
Your answer
Telephone of Physician/Clinic *
Your answer
1st Student Health Alert *
Does child have any health conditions that may affect participation in physical activities?
Required
1st Student Limitations (e.g., stair climbing, participation in gym)
Your answer
1st Student Allergies
Your answer
1st Student 504 services for the current year? *
Section 504 of the Rehabilitation Act created and extended civil rights to people with disabilities. Section 504 provides opportunities for children with disabilities in education and allows for reasonable accommodations and assistance as necessary for each student. Section 504 requires the needs of students with disabilities to be met as adequately as the needs of the non-disabled are met. 504 services provide these accommodations.
1st Student 504 services for the previous year? *
1st Student Has (check any that apply) *
Required
If "No Health Insurance", are you willing to share contact information from this card to learn about insurance options?
If none of the contacts listed on this emergency list 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 judgement of the school authorities will prevail. The recommendation of the parent as indicated below will be respected as far as possible.
Your answer
Does this student have siblings IN A DIFFERENT school? Please give name (First & Last) and School for all siblings NOT at PS 39.
DO NOT list students who also attend PS 39 (that information will be filled in below).
Your answer
Does this student have siblings who attend PS 39? *
'No' will go to the Parent/Guardian section next. 'Yes' will allow entry of a second student's information
PLEASE CLICK CONTINUE....
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