Emergency Contact Card

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Front of Emergency Contact CardPlease click Next!

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Student Last Name

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Student First Name

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Male (M) or Female (F)

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DOB

Date

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Parent/Guardian (Student resides with):

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Relationship (Mother, Father, etc.)

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Parent's Preferred Written Language of Communcation

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Parent's Preferred Oral Language of Communcation

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Parent Cell Phone Number

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Parent/Guardian Work Telephone

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Parent/Guardian Home Telephone

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Parent Email

example@example.com

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Parent Street Address

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Apartment Number

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Borough

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ZIP Code

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Other Parent/Guardian Full Name

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Other Parent/Guardian Relationship (Mother, Father, etc.)

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Other Parent/Guardian's Preferred Oral Language

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Other Parent/Guardian's Preferred Written Language

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Other Parent/Guardian's Home Phone Number

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Other Parent/Guardian's Work Phone Number

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Other Parent/Guardian's Cell Phone Number

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Other Parent/Guardian's Email

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Other Parent/Guardian's Street Address

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Other Parent/Guardian's Apartment Number

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Other Parent/Guardian's Borough

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Other Parent/Guardian's ZIP Code

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Emergency Contact #1 Full Name

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Emergency Contact #1 Phone Number

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Emergency Contact #1 Relationship to Student

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Emergency Contact #2 Full Name

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Emergency Contact #2 Phone Number

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Emergency Contact #2 Relationship to Student

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Emergency Contact #3 Full Name

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Emergency Contact #3 Phone Number

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Emergency Contact #3 Relationship

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If YES there is a person who may NOT HAVE ACCESS to child, please type Full Name:

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If YES there is a person who may NOT HAVE ACCESS to child, please indicate Relationship (Mother, Uncle, etc.)

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Does this person have an Order of Protection against them?

Yes

No

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Parent/Guardian Signature

Clear

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Back of Emergency Contact Card

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Name of Physician/Clinic:

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Telephone

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Does your child have any health condition that may affect participation in physical activities?

Yes

No

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If Yes, what physical limitations does your child have?

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Please list any Allergies your child may have:* This field is required.

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What type of Health Insurance does your child have? (Click any that apply)* This field is required.

Private Health Insurance

Medicaid

No Health Insurance

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Finally, if none of the Emergency Contacts on this card can be reached, what do you wish the school to do if your child is sick or injured?