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Emergency Contact Form

Complete this form to make changes to your child's Emergency Contact Card.

School Year*

Answer required for "School Year"

Student Last Name, First Name, Middle Initial*

Answer required for "Student Last Name, First Name, Middle Initial"

Student DOB (Month/Day/Year)*

Answer required for "Student DOB (Month/Day/Year)"

Student Sex (M or F)*

Answer required for "Student Sex (M or F)"

Grade and Class Number*

Answer required for "Grade and Class Number"

Parent/ Guardian Last Name, First Name (Who Student Resides With)*

Answer required for "Parent/ Guardian Last Name, First Name (Who Student Resides With)"

Relationship*

Answer required for "Relationship"

Home Address *

Answer required for "Home Address "

Cell Phone Number*

Number Required

Work Phone Number

Number Required

Email Address*

Answer required for "Email Address"

Parent's Preferred Language Communication-Written*

Answer required for "Parent's Preferred Language Communication-Written"

Parent's Preferred Language Communication-Oral*

Answer required for "Parent's Preferred Language Communication-Oral"

Other Parent/ Guardian Last Name, First Name

Answer required for "Other Parent/ Guardian Last Name, First Name"

Other Parent/ Guardian Relationship

Answer required for "Other Parent/ Guardian Relationship"

Other Parent/ Guardian Address

Answer required for "Other Parent/ Guardian Address"

Other Parent/ Guardian Cell Phone Number

Number Required

Other Parent/ Guardian Work Number

Number Required

Other Parent/ Guardian Email Address

Answer required for "Other Parent/ Guardian Email Address"

Other Parent/ Guardian's Preferred Language Communication-Written

Answer required for "Other Parent/ Guardian's Preferred Language Communication-Written"

Other Parent/ Guardian's Preferred Language Communication-Oral

Answer required for "Other Parent/ Guardian's Preferred Language Communication-Oral"

List at least 3 people who may be called in case of emergency or if child is sick in school. (Name, Phone Number, Relatioship)*

Answer required for "List at least 3 people who may be called in case of emergency or if child is sick in school. (Name, Phone Number, Relatioship)"

If there is a person who may NOT HAVE ACCESS to your child, please indicate: (Name, Relationship, If Court Order of Protection Exists)

Answer required for "If there is a person who may NOT HAVE ACCESS to your child, please indicate: (Name, Relationship, If Court Order of Protection Exists)"

Name and Phone Number of Student's Physician/ Clinic*

Answer required for "Name and Phone Number of Student's Physician/ Clinic"

Does your child have any health conditions that may affect participation in physical activities? (Yes or No) If yes, please indicate. (Example: stair climbing, participation in gym)*

Answer required for "Does your child have any health conditions that may affect participation in physical activities? (Yes or No) If yes, please indicate. (Example: stair climbing, participation in gym)"

Does your child have allergies? (Yes or No) If yes, please indicate.*

Answer required for "Does your child have allergies? (Yes or No) If yes, please indicate."

If none of the named contacts can be reached, what do you wish the school do if your child is sick or injured? (Example: Take to hospital) It is understood that in the final disposition of an emergency case, the judgement of the authorities will prevail. The recommendation of the parent as indicated will be respected as far as possible.*

Answer required for "If none of the named contacts can be reached, what do you wish the school do if your child is sick or injured? (Example: Take to hospital) It is understood that in the final disposition of an emergency case, the judgement of the authorities will prevail. The recommendation of the parent as indicated will be respected as far as possible."

Signature of Parent/ Guardian*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"