Form 4172 - Student Emergency Contact Card - 2015
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2For office use only:
Broward County Public Schools
Student Emergency Contact Card
School #
Medical
Court Order
Student #
Special Needs
This form shall be updated every year.
Date enrolled
Other
In the case of an emergency, it is imperative that the school be able to reach the student’s parent (as defined below). Please fill in the information
on both sides of this card carefully and accurately. Please use ink and print clearly. The names of both parents of a student (as defined in the
Section 1000.21(5), Florida Statutes), the registering parent and the non-registering parent, of a student shall be listed on the emergency
contact card as persons authorized to pick up the child from school except where a court order has revoked the parental rights and a certified
copy of such court order has been provided to the school office.
Both parents shall designate on the Emergency Contact Card those persons authorized to pick their child up from school. No parent shall delete
or in any way alter the names provided by the other parent on the Emergency Contact Card.
Last
First
Middle
Female
Male
Teacher (elementary school only)
Gender
Grade Level
Home Address
City
State
Zip
Home Phone
/
/
Mailing Address (if different from above)
City
State
Zip
Date of Birth
Student lives with:
Has student changed address
Is there a court order on file that prevents a
Check any that apply to student residence:
since last registration?
parent from having contact with the student?
Medical
Special Needs
Yes
No
Yes
No (If yes, contact school.)
Court Order
Other
Last
First
Email
Home Address
City
State
Zip
Home Phone
Employer
Work Phone
Cell Phone
Last
First
Email
Home Address
City
State
Zip
Home Phone
Employer
Work Phone
Cell Phone
Please list the names of persons to whom we may release your child or whom we may contact if we cannot reach you. NO STUDENT WILL BE
RELEASED TO ANYONE OTHER THAN THE PERSONS LISTED BELOW. In selecting someone to whom you authorize the release of your child,
consider: Is 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, evacuation, or other emergency that may
occur while the student is in school.
Name
Relationship
Home Phone
Work or Cell Phone
I declare that the information on this card is true and correct. I will notify the school office immediately of any changes.
Signature
Date
Relationship
This section may be completed only by the non-registering parent in order to designate additional persons who may pick up the student. The
registering parent may not alter this section of this card. The non-registering parent may not alter any other portion of this card.
Name
Relationship
Home Phone
Work or Cell Phone
I declare that the information on this card is true and correct. I will notify the school office immediately of any changes.
Signature
Date
Relationship
Form 4172 Revised 05/13
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