BTECH 2022-2023 EMERGENCY BLUE CARD
PLEASE COMPLETE THIS FORM FOR YOUR STUDENT.
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Email *
Student Grade in September 2022 *
Student Last Name *
Student First Name *
Date of Birth (mm/dd/yyyy)
Parent/Guardian Last name (Student resides with/Primary) *
Parent/Guardian First name *
Relationship to student *
Parent's Preferred Language  of Communication
Email Address for parent *
Parent Primary Contact Number *
Secondary Contact Number
House Address - This address (mailing) is also the address that will be on file for the student *
City *
State *
Zip Code *
Apartment number
ADDITIONAL PARENT/GUARDIAN LAST NAME  
ADDITIONAL  PARENT/ GUARDIAN FIRST NAME  
Student resides with above parent/guardian
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Address  (Only fill out if the additional parent/Guardian DOES NOT live with student)
Contact Number
Email
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