Emergency Information  Very Important - This form must be completed!

Student Name:      Date: 

Parent(s)/Guardian(s) Information: 

1. Name

          Address

          Home Phone             Work Phone

2. Name

   Address

    Home Phone             Work Phone

Emergency Contact Information: 

1. Name

          Address

          Home Phone             Work Phone

          Relationship to Child Aunt Family Friend/Neighbor Grandparent Step-Parent Uncle   Other

2. Name

   Address

   Home Phone             Work Phone

          Relationship to Child Aunt Family Friend/Neighbor Grandparent Step-Parent Uncle   Other

Hospital/Clinic Information:

Should we be unable to make contact with any of the emergency contacts listed above, your child will be transferred to the nearest hospital.

Name of Clinic

Address   Phone

Policy/Group Number

Primary Care Physician

Primary Care Hospital

Address   Phone

Other Instructions:

Does the student have any medical problems, conditions or allergies that the school should know about?

Any additional comments or special instructions:

I understand the above and I am in agreement.

              Please type in your name                                    Please type in the date

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