Classroom Emergency Information

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Classroom Emergency Information
Child’s Full Name
Date of Birth
/
/
.
Male ( ) Female ( )
( ) American Indian/Alaskan Native
( ) Asian or Pacific Islander
( ) Black (Not of Hispanic Origin)
( ) Hispanic
( ) White (Not of Hispanic Origin)
( ) Multi-Racial
Parent 1 or Guardian
Parent 2 or Guardian
Name
Address
City/State/Zip
Home Phone
Employer
Occupation
Work Phone
Cell#/Beeper
Email
Allergies/Special Needs
Only the people listed below (other than parents or guardians) are allowed to pick-up my child at the
school. In the event of an emergency, these people can be called if parents are not available.
Name
Street Address City, State, Zip
Home #
Work #
Relationship

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