Lehi Literacy Center Emergency Contact Information Form printable pdf download

Lehi Literacy Center Emergency Contact Information Form

_________________________

Student’s Last Name

Guardian’s Last Name

Lehi Literacy Center Emergency Contact Information Form

Occasionally a student may become ill or have an accident while at the center. This may

necessitate contacting the guardian or seeking medical attention for the student. The

information you provide below will allow us to care for your student in case of an

emergency. Please notify the center of any changes regarding this information.

This form does need to be filled out yearly (from the date that the center receives it).

Guardian Name: _________________________ Phone: __________________________

Email: __________________________________________________________________

(Providing an email address grants permission for the Lehi Literacy Center to contact via email)

Address: ________________________________________________________________

(Please include City and Zip Code)

Emergency Contact Name: _________________________________________________

Emergency Contact Phone: _________________________________________________

Please provide the name and number of an out of area (out of Utah County) person whom

you want contacted in the case of a natural disaster:

Out of Area Contact Name: _________________________________________________

Out of Area Contact Phone: _________________________________________________

_________________________

Signature of Guardian

Relationship to Student(s)

_________________________

Date

Student(s)

Male /

Birth Date

Grade

School

Health

(00/00/00)

Name(s)

Female

Issues

(01/09/13)

Lehi Literacy Center Emergency Contact Information Form