Emergency Contact Form - St. Anthony School Kailua
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1
2EMERGENCY CONTACT FORM
Child/Family Last Name:
Mailing Address: _______________________________________
City, State, Zip: _________________________________ _ Home Phone: _______________
_
Catholic: _____yes ____ no
Parish where registered: _____________________________________________
Email: ___________________________________________
Student’s Name
Grade
Birth Date
1.
______________________________________
___________
______________________________________
2.
______________________________ _______
__________ _
______________________________________
3.
______________________________ _______
____________
______________________________________
4.
______________________________ ________
____________
______________________________________
Name
Place of Work
Work Phone
Cell Phone
Father: ___________________________
_______________________
_______________
_______________
Mother: __________________________
_______________________
______________
_______________
IF PARENTS ARE UNAVAILABLE, PLEASE CALL: List relatives or friends approved to pick up your child (the school may ask this person
to pick up your child if you cannot be reached).
Name
Phone
Relationship
_____________________________________
_____________
__________________________________________________
_____________________________________
_ __________ _
__________________________________________________
In case of an emergency the school will call 911 and then the parents.
1.
___________________________________
____
______________________________________________
(Name and phone no. of local doctor)
(Name and phone no. of local dentist)
2.
_________________________________________
________________________________________
__
(Medical Insurance Co.)
(Policy)
3.
_________________________________________ _
___________________________________________ __
(Allergies)
No medication, Tylenol, topical cream, sunscreen or otherwise will be administered from the office without written
instructions from the parent. NO VERBAL permission will be allowed. Renew with each new request. Please list on your
child(ren’s) Health Form any allergies or medical conditions they may have.
____________________________________________________
__________________________________________
Parent/Guardian Signature
Date
PLEASE REPORT ANY CHANGES TO THE SCHOOL OFFICE
St. Anthony School
148 Makawao St.
Kailua, HI 96734
808-261-3331
FAX 808-263-3518
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