Student Emergency Contact PDF Form

Student Emergency Information Card

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

First Name Last Name
Nickname
Birthdate *

Month Day Year
Age *
Class *
Parent/Guardian
Parent/Guardian *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Email *
example@example.com
Second Parent Name

First Name Last Name
Second Parent Phone Number

Area Code Phone Number
Second Address

Street Address

Street Address Line 2

City State

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 Name Last Name
Best Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Name *

First Name Last Name
Best Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

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
Should be Empty:

Student Emergency Information Card