STUDENT EMERGENCY CONTACT CARD
Office Use Only
In case of an emergency, it is imperative that the school be able to reach the student’s
Parent (as defined below). Please fill in the information on both sides of this card carefully
and accurately. Please use ink and print clearly. “Parent” includes any adult exercising
supervisory authority over a student (section 1000.21(5) Fla.Statute.)
Lives with: Mother Father Both Parents Other ____________
Mailing Address, if different from above
Address change? No Yes If Yes, please contact the School Office.
__________________|___|____________________ (2) _______________________|___|___________________
Other children at home: (1)
Languages spoken at home: 1.
Has a court prohibited the parent from having contact with the student? No Yes
If Yes, contact the School Office.
Please list the names of persons to whom we may release your child or who we may contact if we cannot reach you. NO STUDENT WILL BE RELEASED TO ANYONE
OTHER THAN THE PERSONS LISTED BELOW. In selecting someone to whom you authorize the release of your child, consider:
this person prepared to handle any
special medical needs required by your child?
I/we hereby authorize contact with, release of emergency related information, or release of the student to the following
persons in the event of illness, injury, evacuation or other emergency that may occur while students are in school.
Work or Cell Phone
I declare that the information on this form is true and correct. I will notify the school office immediately of any changes
Form 4710 Rev. 5/17/11