Form 4710 - Student Emergency Contact Card
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1
2STUDENT EMERGENCY CONTACT CARD
Emergency Contacts
Office Use Only
In case of an emergency, it is imperative that the school be able to reach the student’s
School #
Parent (as defined below). Please fill in the information on both sides of this card carefully
FSI#
and accurately. Please use ink and print clearly. “Parent” includes any adult exercising
Date Enrolled
supervisory authority over a student (section 1000.21(5) Fla.Statute.)
________
Grade
r
MEDICAL
r
RESTRAINING ORDER
STUDENT
_____________________________________________________
____________________
r
Male
SPECIAL NEEDS
Last Name
First
Middle
Female
Teacher/Advisor
r
OTHER
________________________________________________________________________________|____________|__________________
Home Address
City
State/Zip
Home Phone
Birthdate
Birthplace
_____________________________
_____________________________________________________________
Lives with: Mother Father Both Parents Other ____________
Mailing Address, if different from above
City
State/Zip
Address change? No Yes If Yes, please contact the School Office.
REGISTERING PARENT
____________________________________________________________________|_________________________
Last Name
First
Email
Employer
________________________________________________________________________________|_______________|_______________
Home Address
City
State/Zip
Home Phone
Work Phone
Cell Phone
OTHER PARENT
_________________________________________________________________________|__________________________
Last Name
First
Email
Employer
____________________________________________________________ ____________________|_______________|_______________
Home Address,
City
State/Zip
Home Phone
Work Phone
Cell Phone
__________________|___|____________________ (2) _______________________|___|___________________
Other children at home: (1)
Name
Grade
School
Name
Grade
School
______________________________________
_______________________________________________
Languages spoken at home: 1.
2.
Has a court prohibited the parent from having contact with the student? No Yes
If Yes, contact the School Office.
AUTHORIZED Release/Contact
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
Is
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.
Name
Relationship
Home Phone
Work or Cell Phone
Out-of-state contact:
I declare that the information on this form is true and correct. I will notify the school office immediately of any changes
___________________/_____________________
_____________
________________________
Parent’s Signature
Date
Relationship
Form 4710 Rev. 5/17/11
Continued ð
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