School District Of Philadelphia Emergency Contact Form
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1Sex
Grade
Rm.-Sec.-Bk.
EH-4 (Rev. 7/08)
SCHOOL DISTRICT OF PHILADELPHIA
EMERGENCY CONTACT FORM
Student ID
Student’s Name
Birth Date
School No.
Address
Apt. No.
Home Phone
Enter Child’s Pennsylvania I.D. Number
Does your child have health insurance?
___ Yes
___ No
If Yes, check the appropriate health insurance below:
Name of Child’s Doctor/Clinic
Phone No.
__ Aetna/US Health Care
__ Blue Cross
__ Health Partners
__ AmeriChoice
Name of Child’s Dentist/Clinic
Phone No.
__ Keystone Mercy
__ Keystone Health Plan East
__ Other___________________
First Emergency Contact - Parent/Guardian
Relationship to child
Daytime Phone
Cell Phone
E-Mail
Second Emergency Contact (full name)
Third Emergency Contact (full name)
EH-4 (Rev. 7/08)
SCHOOL DISTRICT OF PHILADELPHIA
Sex
Grade
Rm.-Sec.-Bk.
EMERGENCY CONTACT FORM
Student ID
Student’s Name
Birth Date
School No.
Address
Apt. No.
Home Phone
Enter Child’s Pennsylvania I.D. Number
Does your child have health insurance?
___ Yes
___ No
If Yes, check the appropriate health insurance below:
Name of Child’s Doctor/Clinic
Phone No.
__ Aetna/US Health Care
__ Blue Cross
__ Health Partners
__ AmeriChoice
Name of Child’s Dentist/Clinic
Phone No.
__ Keystone Mercy
__ Keystone Health Plan East
__ Other___________________
First Emergency Contact - Parent/Guardian
Relationship to child
Daytime Phone
Cell Phone
E-Mail
Second Emergency Contact (full name)
Third Emergency Contact (full name)
Sex
Grade
Rm.-Sec.-Bk.
EH-4 (Rev. 7/08)
SCHOOL DISTRICT OF PHILADELPHIA
EMERGENCY CONTACT FORM
Student ID
Student’s Name
Birth Date
School No.
Address
Apt. No.
Home Phone
Enter Child’s Pennsylvania I.D. Number
Does your child have health insurance?
___ Yes
___ No
If Yes, check the appropriate health insurance below:
Name of Child’s Doctor/Clinic
Phone No.
__ Aetna/US Health Care
__ Blue Cross
__ Health Partners
__ AmeriChoice
Name of Child’s Dentist/Clinic
Phone No.
__ Keystone Mercy
__ Keystone Health Plan East
__ Other___________________
First Emergency Contact - Parent/Guardian
Relationship to child
Daytime Phone
Cell Phone
E-Mail
Second Emergency Contact (full name)
Third Emergency Contact (full name)
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