Kindergarten 2024-2025                                      PS 46 - Blue Card - Emergency Contact info

Emergency Contact Card Information

As always, safetys the highest priority there is for our school community.
In order to ensure we have current and accurate contact information before this school term begins, it is imperative that the following information be provided until hard copy “blue” emergency cards may be completed.
This information is known to school staff only, including the nurse.
Thank you

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Please complete the following information below. Please notify the main office and your child's teacher if you ever need to make any changes or updates. 
Email  *
Student Last Name   
 *
Student First Name 
 *
Student Grade *
Required
Kindergarten Class *
Date of Birth of Student (mm/dd/yyyy)  
 *
MM
/
DD
/
YYYY
Gender of Student
 *
Does the student have health insurance?
 *
Would you like to be contacted about getting health insurance coverage?
 *
PARENT / GUARDIAN INFORMATION
For parent 1, please provide the information of a parent/guardian with whom the student resides. 
Last Name of Parent 1
 *
First Name of Parent 1 
 *
Relationship of Parent 1 (e.g., mother, father) 
 *
Cell Phone Number of Parent 1 
 *
Work Phone of Parent 1 
Email of Parent 1  *
Preferred Written Language of Parent 1  *
Preferred Spoken Language of Parent 1 *
Home Address of Parent 1 (house number, street, apt, city)  *
Zip Code of Parent 1 Address  *
Is this a new address for the student (different from what we have on record)?*
 *
OTHER PARENT/GUARDIAN INFORMATION
Last Name of Parent 2
First Name of Parent 2
Relationship of Parent 2 (e.g., mother, father)
Cell Phone Number of Parent 2
Work Phone Number of Parent 2
Preferred Written Language of Parent 2
Clear selection
Preferred Spoken Language of Parent 2
Clear selection
Home Address of Parent 2 (house number, street, apt, city)
Zip Code of Parent 2 Address
OTHER EMERGENCY CONTACTS - List below names of additional persons who may be called in case of emergency or if child is sick in school. CHILD WILL ONLY BE RELEASED TO PERSONS NAME HERE OR ON THE EMERGENCY CONTACT CARD. 
Name of Emergency Contact 1
 *
Phone Number of Emergency Contact 1
 *
Relationship to Student of Emergency Contact 1
 *
Name of Emergency Contact 2
 *
Phone Number of Emergency Contact 2
 *
Relationship to Student of Emergency Contact 2
 *
Name of Emergency Contact 3
 *
Phone Number of Emergency Contact 3
 *
Relationship to Student of Emergency Contact 3

 *
STUDENT HEALTH INFORMATION
Name of Physician/Clinic
 *
Physician/Clinic Phone Number
 *
Does child have any health condition that may affect participation in physical activities?
 *
Limitations (e.g., stair climbing, participation in gym
 *
Allergies*
 *
504 services for the current year
 *
504 services for the previous year

 *
If none of the named contacts 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 judgment of the school authorities will prevail. The recommendation of the parent as indicated here will be respected as far as possible.
 *
NO ACCESS
IF there is a person who may NOT HAVE ACCESS to this child, please indicate that here. 
Name of Person with NO Access
Relationship of Person with NO Access
Order of Protection Exists Against This Person?
Clear selection
STUDENT'S SIBLINGS   
Last Name of Sibling 1 (if any)
First Name of Sibling 1 (if any)
What is the relationship of Sibling 1?
Clear selection
School of Attendance for Sibling 1 (if any)
Last Name of Sibling 2 (if any)
First Name of Sibling 2 (if any)
What is the relationship of Sibling 2?
School of Attendance for Sibling 2 (if any)
Last Name of Sibling 3 (if any)
First Name of Sibling 3 (if any)
What is the relationship of Sibling 3?

School of Attendance for Sibling 3 (if any)
Please use this area to write anything else you would like to share with P.S. 46
Signature of parent/guardian completing this form.  *
Date *
MM
/
DD
/
YYYY
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