Emergency Information Form - Lancaster Mennonite

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Emergency Information
Student Name: ______________________________ Grade: ________ Gender: _____
Street Address: ____________________________________________________________
City: __________________________________ State: ___ Zip Code: _____________
Mother’s Name: __________________________
Home phone: ___________________
Mother’s Employer: ________________________ Work phone: ___________________
Campus:
Cell phone: ____________________
Kraybill
Lancaster
Father’s Name: __________________________
Home phone: ___________________
Locust Grove
Father’s Employer: ________________________
Work phone: ___________________
New Danville
Cell phone: ____________________
It is important to have
this information on file in
Guardian’s Name: _________________________ Home phone: ___________________
the event of a medical
Guardian’s Employer: _______________________ Work phone: ___________________
emergency or other
emergency involving your
Cell phone: ____________________
child. Although some of
this information is in our
Student lives with :
Both parents
Mother
Father
Guardian
Foster Family
Mother & Stepfather
Father & Stepmother
Other: ________________________
database or other school
records, a hard copy of
Custody information on file with the school?
Yes
No
this sheet will be available
(please check one if separated or divorced)
for easy access in
Emergency Contacts (other than parents)
emergencies when the
computers may not be
Name: __________________________________
Relationship: ___________________
operational
.
Phone: _________________________________
Alternative phone: _______________
Name: __________________________________
Relationship: ___________________
Phone: _________________________________
Alternative phone: _______________
Name: __________________________________
Relationship: ___________________
Phone: _________________________________
Alternative phone: _______________
Physician’s Name: _______________________
Physician phone: _________________
Dentist’s Name: __________________________
Dentists’ phone: _________________
In the event of an emergency , the school will attempt to contact the parents, guardians and
emergency contact persons. If the school is unable to reach them, the undersigned authorizes
the school to contact the physician listed above and follow his/her instructions. If the physi-
cian cannot be reached, the undersigned authorizes the school to make whatever arrange-
ments it deems necessary for the health and safety of the child.
Parent/Guardian signature: _________________________ Date: ____________________

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