Emergency Information Sheet printable pdf download

1085 Eggert Road

Amherst, New York 14226

(716)836-6903

Emergency Information Sheet

2017-2018

Please fill out ENTIRE sheet

Please print all information

Student’s Name____________________________________________ Grade_________ Date of Birth_______________

Address_____________________________________City_________________________________Zip_______________

Home Phone _______________________________________ Cell Phone _____________________________________

School District ___________________________________________

Parent 1

Name________________________________________________ Email________________________________________

Cell #______________________________________________ Work # _________________________________________

Parent 2

Name________________________________________________ Email________________________________________

Cell #______________________________________________ Work # ________________________________________

List 2 alternative adults to contact if parents are unavailable. Must be able to pick up student from school.

Name__________________________________________ Relationship ___________________________________

Cell #______________________________________________ Work # ____________________________________

Name__________________________________________ Relationship ___________________________________

Cell #______________________________________________ Work # ____________________________________

Students Physicians Name ____________________________________________Phone #__________________________

Hospital of choice: ____________________________________________

List all medications taken on a regular basis: _______________________________________________________________

___________________________________________________________________________________________________

List all health conditions:______________________________________________________________________________

__________________________________________________________________________________________________

LIST ALL ALLERGIES AND THEIR REACTIONS _________________________________________________________

_________________________________________________________________________________________________

Parent Signature_________________________________________________

DATE:______________

Emergency Information Sheet