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Emergency Form (one per family)

EMERGENCY FORM

2023/2024 school year

PLEASE FILL OUT COMPLETELY AND ACCURATELY, AS THIS INFORMATION WILL BE USED IF YOUR CHILD BECOMES INJURED OR IS IN NEED OF EMERGENCY MEDICAL ATTENTION.

*Please list children from oldest to youngest.

Student Full Name*

Answer Required

Grade*

Answer Required

Birthdate*

Answer Required

Student Full Name

Answer Required

Grade

Answer Required

Birthdate

Answer Required

Student Full Name

Answer Required

Grade

Answer Required

Birthdate

Answer Required

Student Full Name

Answer Required

Grade

Answer Required

Birthdate

Answer Required

PRIMARY FAMILY INFORMATION:

Parent Names*

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Email 1*

Answer Required

Email 2

Answer Required

Dad Mobile Phone

Number Required

Dad Work Phone

Answer Required

Mom Mobile Phone

Number Required

Mom Work Phone

Number Required

Parent Living Elsewhere

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Emergency Contact Information

First Name*

Answer Required

Last Name*

Answer Required

Relationship*

Answer Required

Phone*

Number Required

Home Phone

Number Required

Please be sure to let your emergency contact person know that you have listed them as the “contact person” for your child(ren). They will be contacted should we be unable to reach you.

In the event that neither you or your emergency contact can be reached, please list a physician that the school may contact to follow his or her instructions. If your physician cannot be reached, the school will make whatever arrangements are necessary.

Physician's Name*

Answer Required

Phone *

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Hospital Preference (in the event of an emergency the nearest facility would be utilized)*

Answer Required

Dentist Name*

Answer Required

Phone*

Answer Required

I authorize the physician, dentist, and/or hospital listed on this document to treat my child in the event of serious illness or injury, when I or the persons listed on this form cannot be reached. Any obligation for medical expenses resulting from treatment in such a case is my responsibility. Permission to transport my child in case of emergency is also given.

By signing this form, I attest that I provided the above information and that it is accurate to the best of our knowledge.

Parent Signature*

Signature Required

Confirmation Email

Confirmation Email *

Email Required