EMERGENCY CONTACT CARD

Student First Name & Last Name

Student First NameStudent Last Name

Middle Initial

Month of Birth (MM: 01, 02, 03)

Day of Birth (DD: 01, 02...)

Year of Birth (YYYY: 2000, 2001, 2002)

Gender (Female, Male, Non-Binary)

OSIS # / Student ID

Parent/Guardian Last Name (Student resides with)

Parent/Guardian First Name (Student resides with)

Parent/Guardian Relationship (Mother, Father, Aunt...)

Parent’s Preferred Language of Communication (Written)

Parent’s Preferred Language of Communication (Oral)

Parent’s Home Telephone

Parent’s Work Telephone

Parent’s Cell Phone

Parent/Guardian Email Address

example@example.com

Street Address where Student Resides (House Number: 123 Main St)

Apartment #

City

Zip Code

Borough

Other Parent/Guardian’s Last Name & First Name

Other Parent/Guardian Last NameOther Parent/Guardian First Name

Other Parent/Guardian’s Relationship (Mother, Father, Uncle...)

Other Parent/Guardian’s Preferred Language of Communication (Written)

Other Parent/Guardian’s Preferred Language of Communication (Oral)

Other Parent/Guardian’s Home Telephone

Other Parent/Guardian’s Work Telephone

Other Parent/Guardian’s Cell Phone

Other Parent/Guardian’s Email

example@example.com

Other Parent/Guardian’s Address (House Number: 123 Main St)

Other Parent/Guardian 's Apartment #

Other Parent/Guardian 's City

Other Parent/Guardian 's Zip Code

Other Parent/Guardian 's Borough

List below names of three (3) persons who may be called in case of emergency or if child is sick in school. CHILD WILL ONLY BE RELEASED TO PERSONS NAMED ON THIS CARD. PLEASE TRY YOUR BEST TO PROVIDE THREE ADULT EMERGENCY CONTACTS!

CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD.

	First Name + Last Name	Telephone	Relationship
Adult 1
Adult 2
Adult 3

If there is a person who may NOT HAVE ACCESS to child, please indicate:

Full NameRelationship

Order of Protection Exists?

YesNo

Health Information

Name of Physician/ClinicTelephone

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

YesNo

Does your student have any Limitations (e.g., stair climbing, participation in gym)

Does your student have any ANY ALLERGIES (Allergies i.e. allergic to peanuts, shellfish, etc.)

Did Your Student have Section 504 Medical Accommodation Services for the current year 2022-2023? (504 Accommodations are health services or medical accommodations that your student medically needs, i.e. medicines/treatments for asthma, allergies, or seizures)

YesNo

Did Your Student have Section 504 Medical Accommodation Services for any Previous Years?

YesNo

Does your student have Health Insurance? Please mark the health insurance your student has (X any that apply please):

Private health insuranceMedicaidNo health insurance

If “No Health Insurance,” are you willing to share contact information from this card to learn about insurance options?

YesNo

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?

It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.

SIBLINGS: Please list the names and schools of your student's siblings below.

	Sibling's Last Name	Sibling's First Name	Sibling's School of Attendance

Principal will be notified in writing of any changes to information on this card. Please touch and hold down on your screen to add your signature or click and hold down on your mouse to sign below.

EMERGENCY CONTACT CARD

STUDENT INFORMATION

EMERGENCY CONTACTS

NO ACCESS

HEALTH INFORMATION

Health Alert

SIGNATURE OF PARENT/GUARDIAN