Student Emergency Contact Form
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2Charleston Elementary School
2013 – 2014 Student Emergency Contact Form
E
C
P
– M
C
P
MERGENCY
ONTACTS
AGE
EDICAL
ONSENT
AGE ON OTHER SIDE
In case of an emergency, it is imperative that the school be able to reach the student’s parent or guardian. Please fill in the information on
both sides of this form carefully and accurately. Please type or use ink and print clearly and legibly.
STUDENT ________________________________________________________________
Male __ Female ____ Grade _____
Last Name
First
Middle
Social Security #
____________________________________________________________________________ Home Phone ________________ Birthdate _________
Home Address (Primary Residence)
City
Zip
____________________________________________________________________________ Lives with (circle below):
Mailing Address, if different than above
Both Parents
Mother Father Legal Guardian
MOTHER/GUARDIAN ____________________________________
_______________________
________________
Last Name
First
Employer
Work Phone
____________________________________________________________________
___________________________
____________________
Home Address, if different than above
City
Zip
Phone
Cell Phone
FATHER/ GUARDIAN ____________________________________
_______________________ _________________
Last Name
First
Employer
Work Phone
____________________________________________________________________
___________________________
____________________
Home Address, if different than above
City
Zip
Phone
Cell Phone
Are there any court mandated custody / visitation orders limiting access to this student? Yes____ No____ (if Yes, please attach a copy of the
legal order and list those named therein): _____________________________________________________________________________________
Please list siblings and their ages:
Name
Age
Name
Age
Name
Age
AUTHORIZED CONTACTS
Please list the names of relatives/neighbors/friends in close proximity to the school to whom we may release your
child or contact if you cannot be reached. NO STUDENT WILL BE RELEASED TO ANYONE OTHER THAN THE PARENTS, GUARDIANS, OR
ADULTS LISTED ON THIS PAPER. In selecting someone to whom you authorize the release of your child, consider: (a) Would your child feel safe and
comfortable with this person? (b) Could this person care for your child for several days? (c) Is this person prepared to handle any special medical needs
required by your child?
I/we hereby authorize the release of the student named above to the following persons in the event of illness, injury, evacuation or
emergency that may occur while students are in school.
Name
Relationship
Home Phone
Work or Cell Phone
I declare that the information on this form is true and correct. I will notify the school immediately of any changes to be made to this form.
Parent/Guardian signature ____________________________________ Date _____________ Relationship ______________________
Please continue to the back page…
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