Student Emergency Contact PDF Form

Student Emergency Information Card

This form Must be updated at least annually
Personal Information
Students Name*

First NameLast Name
Nickname
Birthdate*

MonthDayYear
Age*
Class*
Parent/Guardian
Parent/Guardian*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Email*
example@example.com
Second Parent Name

First NameLast Name
Second Parent Phone Number

Area CodePhone Number
Second Address

Street Address

Street Address Line 2

CityState

Zip Code
Second Email
example@example.com
Health Information
IN CASE OF AN EMERGENCY, PLEASE NOTIFY

Please provide two separate contacts that are not Mom or Dad.
Name*

First NameLast Name
Best Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name*

First NameLast Name
Best Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Special Health/ Medical Needs*
Please list all needs such as medical, mental, emotional, developmental, social or otherwise and any specific care instructions
Special Dietary Needs*
For infants please include any milk or formula your child is on
Allergies*
Please list all seasonal, environmental, dietary allergies
Medications Taken on a Regular Basis*
Please include all medications, current or just finished, as well as topical creams, over the counter or prescribed
Local Physician/Number*
Please include the practice, Primary care physician a phone number and address
Health Insurance Provider*
Policy Number*
Religious Information Pertinent in a Medical Situation
I agree and attest that I the information above is accurate to my knowledge and agree to update any of the above information at least annually. By signing this form you are stating and agreeing that this information is updated and will be valid for one year from the date of completion.
Signature

Clear
Date Completed:

MonthDayYear
Date
Should be Empty:

Student Emergency Information Card