Student Emergency Contact Form printable pdf download

Student Information and Emergency Contact Form

2016-2017 School Year

Please Print Clearly. If information changes after school begins, call the main office.

Student Information

Grade:

Student Name : _______________________________________________________

Street Address: _______________________________________________________

City: _____________________________ Zip Code: ____________ Home Phone:_____________

Date of Birth: _______/ _______/_________Gender :

Male

Female

Student lives with:

Both Parents

Mother

Father

Guardian(s)

Other:____________

Please list all siblings:

Name: _______________Age: _____ School:___________ Name: ______________Age:____ School:____________

PARENT INFORMATION

Mother/Guardian : _______________________________________________________

Address: _______________________________________________________

Employer: ___________________Occupation:______________ Work Phone:___________

Home Phone:____________________ Cell Phone:___________

Email Address:________________________________________

Father/Guardian : _______________________________________________________

Address: _______________________________________________________

Employer: ___________________Occupation:______________ Work Phone:___________

Home Phone:____________________ Cell Phone:___________

Email Address:________________________________________

EMERGENCY CONTACTS

1. Name: _______________________________Relationship to student : ______________

Address: _______________________________________________________

Home Phone: ______________Cell Phone: ______________ Work Phone:___________

2. Name: _______________________________Relationship to student : ______________

Address: _______________________________________________________

Home Phone: ______________Cell Phone: ______________ Work Phone:___________

Student Emergency Contact Form