Emergency Student Information Form printable pdf download

EMERGENCY STUDENT INFORMATION

Last Name ________________________________ First Name _________________________________ MI _______

Birth Date (month/day/year) _____________________________ Year in School ______________

Home Address: Street _______________________________________________

Town _________________________________ State _______________ Zip Code _____________

County _______________________________ Home Phone ______________________

Name of Mother _____________________________________ Home Phone ____________ Cell Phone ____________

Employer _________________________________________________

Business Phone __________________

Name of Father ______________________________________ Home Phone ____________ Cell Phone ____________

Employer _________________________________________________

Business Phone __________________

The student lives with (circle as applicable): Mother

Father

Guardian

Other _________________________

Legal Guardian

____________________________________________________

(if different from above)

Home Phone ______________________

Cell Phone ______________________

ALLERGIES ____________________________________________________________________________________

MEDICATIONS TAKEN REGULARLY ____________________________________________________________

SPECIAL HEALTH CONDITIONS (if applicable) ____________________________________________________

IN CASE OF AN EMERGENCY

I hereby authorize the following people to be called and/or to pick up my child in case of illness, emergency, or any

other reason if parental contact cannot be made:

1. Name _____________________________________ Relationship ______________ Phone Number ____________

2. Name _____________________________________ Relationship ______________ Phone Number ____________

Doctor Preference ____________________________________________________

Address ____________________________________________________ Phone Number ______________

Hospital Preference ___________________________________________________

Address ____________________________________________________ Phone Number ______________

In the event of an emergency involving my child, I grant permission for school authorities to seek medical care.

In addition, I understand appropriate medical care may include emergency assistance and/or hospitalization. I

authorize the attending physician to render medical and emergency care to my child as necessary. I agree to

assume all responsibility and expense, including transportation costs, incurred for providing medical care.

Parental/Guardian Signature _______________________________________________ Date ___________________

Emergency Student Information Form