Health And Emergency Information Form Page 2
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2Name: ___________________________________________________________________
Address: __________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Name: ___________________________________________________________________
Address: __________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Permission to pick up my child(ren): In addition to the above, the following are allowed to
pick up my child(ren):
Name: ___________________________________________________________________
Address: __________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Name: ___________________________________________________________________
Address: __________________________________________________________________
Email address: ___________________________ Cell Phone: ___________________Text? Y/N
Home phone: ___________________________ Work phone: __________________________
Emergency Treatment Authorization
I request that my child receive first aid whenever it is deemed necessary. In case of emergency illness or
accident involving my child(ren), Carbondale New School is authorized to proceed with emergency
procedures. I give my permission for authorized school personnel to transport my child(ren) if I cannot
be reached and to seek other emergency care if our family physician cannot be reached.
Parent/Guardian Signature: _________________________________ Date: _______
Parent/Guardian Signature: _________________________________ Date: _______
Please fill out both sides of this document.
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