Student Emergency Contact Form printable pdf download

Student Emergency Contact Form

Student Name: __________________________________________________________ Date of Birth: ________________________

Please identify any known allergies: ______________________________________________________________________________

Address: ____________________________________________________________________________________________________

Home Phone: ______________________ Mother Cell Phone: ____________________ Father Cell Phone: ____________________

Father’s Name: _____________________ Work Phone: __________________________ Employer Name: _____________________

Mother’s Name: ____________________ Work Phone: __________________________ Employer Name: _____________________

Mother’s email: _______________________________________ Father’s email: __________________________________________

First Emergency Contact

Name: ____________________________________________ Relationship: ______________________________________________

Home Phone: _____________________________ Work Phone: _________________________ Cell Phone: ___________________

Address: ____________________________________________________________________________________________________

Other Contact Information: _____________________________________________________________________________________

Second Emergency Contact

Name: ____________________________________________ Relationship: ______________________________________________

Home Phone: ______________________________ Work Phone: _________________________ Cell Phone: __________________

Address: ____________________________________________________________________________________________________

Other Contact Information: _____________________________________________________________________________________

Is your child covered under Health Insurance?

Yes ____

No ____

Name of Insurance: _________________________________________________Policy # __________________________________

I hereby grant permission for BelovED staff to secure emergency medical, psychiatric and/or other services should they be needed and

the school staff is unable to contact me. I am aware that Parents/Guardians are responsible for the financial obligation for such

emergency care and transportation from the hospital.

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Signature of parent/guardian

Student Emergency Contact Form