Emergency Information Form
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Student’s Name: ______________________ ______________________ __________ Last Name First Name Middle Initial
Student’s Address __________________________ ___________ _______ ___________ Street address/ Apt # City State Zip Code
Student’s Age _______Date of Birth _________Student’s Phone Number___________
Grade _________ Teacher (Homeroom)/Classroom________________ Bus # ________
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TO BE COMPLETE BY PARENT’GUARDIAN: TO SERVE YOUR CHILD I N CASE OF ACCIDENT OR SUDDEN ILLNESS, IT IS NECESSARY THAT YOU FURNISH THE FOLLOWING INFORMATION: |
MOTHER’S NAME _____________________ _________________ _______________
Last Name First Name Middle Initial
Mother’s Employer ___________________________________ Phone #_____________
FATHER’S NAME ______________________ _______________ ________________
Last Name First Name Middle Initial
Father’s Employer____________________________________ Phone # _____________
GUARDIAN’S NAME ___________________ ________________ ________________
Last Name First Name Middle Initial
Guardian’s Employer __________________________________ Phone # ____________
In case of emergency, accident, or serious illness of the above named child, I request the school to contact me. If school personnel are unable to contact me, I hereby authorize them to call the following people who are authorized to pick up my child from school or a school-sponsored activity:
___________________________________ ____________________ ________________
Name Phone Number Relationship
___________________________________ ____________________ ________________
Name Phone Number Relationship
Doctor’s Name:______________________________________ Phone #:____________
Address: ______________________________________________________
If it is impossible to contact the physician named above, I hereby authorize the school to take action necessary to maintain the student’s health.
___________________________________________ ___________________
Signature of Parent/Guardian Date
School-Related Student Trip Permission Slip and Medical Release Form
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Student’s Name _____________________ ________________________ __________ Last First Middle
School _______________________ Grade ________ Homeroom_________________
Alternate Destination, If applicable ______________________________________
Mode of Transportation_____________________ Cost to Student, if applicable $______
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I hereby give permission for my child to participate in the above mentioned school-related student trip(s).
In addition, in the event of accident or sudden illness while on the school-related student trip, I authorize school personnel to contact the physician(s) listed on my child’s school enrollment data forms and authorize those physician(s) to render such treatment as may be deemed necessary in an emergence for the health of said child. In the event physician(s), parent(s), or other persons designated by the parent cannot be contacted, school personnel are hereby authorized to take whatever action is deemed necessary in their judgment for the health of said child.
___________________________________________________ __________________
Parent/Guardian’s Signature Date
Please return this form to your child’s teacher.