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Emergency Contact

Student Information

State*
Answer required for "State"

Mother / Guardian Information

Father / Guardian Information

Emergency Contact Information - CHILD WILL BE RELEASED ONLY TO PEOPLE NAMED ON THIS CARD.

NO ACCESS:  If there is a person who may NOT HAVE ACCESS to child, please indicate:

Please submit a copy of the order of protection to your child’s school.
Answer required for "Please submit a copy of the order of protection to your child’s school. "
or drag it here.
Order of Protection Exists?
Answer required for "Order of Protection Exists?"

Health Information

Type of Physician
Answer required for "Type of Physician"
Health Alert Does child have any health condition that may affect participation in physical activities?
Answer required for "Health Alert Does child have any health condition that may affect participation in physical activities?"
Known Diagnoses (please check all that apply)
Answer required for "Known Diagnoses (please check all that apply) "
Allergies (select all that apply)
Answer required for "Allergies (select all that apply)"
My child has (X any that apply):
Answer required for "My child has (X any that apply):"
If “No Health Insurance,” are you willing to share contact information from this card to learn about insurance options? (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 above will be respected as far as possible. )
Answer required for "If “No Health Insurance,” are you willing to share contact information from this card to learn about insurance options? (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 above will be respected as far as possible. )"

SIBLINGS

SIGNATURE OF PARENT/GUARDIAN (By checking this box, I agree to be contacted by elected School, District, and/or City-wide parent leader volunteers regarding events, updates, and other matters connected to my school community. By checking this box, I agree that my contact information can be shared with elected School, District, and/or City-wide parent leader volunteers so I can be updated on events and other matters connected to my school community. *
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Date:
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