Information And Emergency Care Form

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HEARTLAND CHRISTIAN ACADEMY
Information and Emergency Care
PLEASE PRINT (one per student)
Student’s Full Name _________________________________ Birth date_________ Gender_____
Parents’/Guardians’ Names __________________________________
Phone
#_________________
Home Address __________________________________ City ____________ State
______________
Zip _______________ E-mail
Address_____________________________________________________
Work Address_____________________________________________
Occupation(s)_____________
Work Phone #(s) ______________________ Mom Cell ______________ Dad Cell
_______________
Names and ages of other children in the
family____________________________________________
1.
Name of person to call in case of Emergency
______________________________________
Telephone
____________________
Relationship
_____________________________
2.
Name of person to call in case of Emergency
_______________________________________
Telephone
____________________
Relationship
_____________________________
Person(s) authorized to take child from the school:
__________________________________
Relationship
_____________________________
__________________________________
Relationship
_____________________________
__________________________________
Relationship
_____________________________
(Child will not be allowed to leave with any other person without written authorization
from the responsible parent or guardian).
Please highlight any other health concerns or issues of which you would like us to be
aware.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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