Emergency Contact Form
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1CITY__________________________
SCHOOL_______________________
FAMILY NAME___________________
EMERGENCY CONTACT
1. Student Information
Name of Student
Birthdate
Grade
Known Allergies or Medical Conditions
______________
_________
_________
____________________________________
___________________________
_______________
______________
_________
_________
____________________________________
___________________________
_______________
______________
_________
_________
____________________________________
_______________
______________
_________
_________
____________________________________
_______________
______________
_________
_________
____________________________________
_______________
2. Parent/Guardian Information
_______________
Father's/Guardian's name______________________________________Home Tel. #___________________________
_______________
Work Tel. # (w. ext)__________________________________________Cell Tel. #_____________________________
_______________
E-mail__________________________________________________________________________________________
_______________
Mother's/Guardian's name_____________________________________Home Tel. #____________________________
_______________
Work Tel. # (w. ext)__________________________________________Cell Tel. #_____________________________
_______________
E-mail__________________________________________________________________________________________
Parents or guardians listed above have permission to pick up the child, unless otherwise indicated. Notify the head of school
Immediately if there are any court orders restricting noncustodial parents or others from contact with the child. Provide the
head of school with a copy of the order.
3. Child Care Provider Information
Those designated below are authorized to pick up my child from school in an emergency:
______________
Child care provider's name_________________________________________________________________________
______________
Tel. #____________________________________________Cell tel. #_______________________________________
4. Local Contact Information (Designate 2 Parents in our school)
Those designated below are authorized to pick up my child from school in an emergency:
______________
1. Local contact's name__________________________________Relationship to child__________________________
______________
Home tel. #____________________________________________Work tel. #_________________________________
______________
Cell tel. #_____________________________________________E-mail______________________________________
______________
2. Local contact's name_________________________________Relationship to child___________________________
______________
Home tel. #____________________________________________Work tel. #_________________________________
______________
Cell tel. #_____________________________________________E-mail______________________________________
5. Out-Of-Town Contact Information
______________
Name_______________________________________________Relationship to child___________________________
______________
Home tel #___________________________________________Work tel. #___________________________________
______________
Cell tel #______________________________________Email______________________________________________
6. Medical/Physician Information
______________
Doctor's Name____________________________________Tel. #___________________________________________
______________
Hospital preference_______________________________________________________________________________
______________
Insurance Co.____________________________________________________________________________________
______________
Dentist's Name____________________________________Tel. #___________________________________________
In a medical emergency, we hereby authorize the school to seek emergency medical assistance for our child if we cannot
be reached.
______________
Parent/Guardian signature____________________________________________Date__________________________
Please keep a copy of this form for your records. Important: Please update your school immediately of any changes.
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