LADC Student Packet: Emergency Form
Discovery Center Location Attending:
*
Please Select
Annunciation / Minneapolis
Faithful Shepherd / Eagan
Notre Dame Academy / Minnetonka
Presentation of Mary / Maplewood
St. Bart's / Wayzata
St. Helena's / Minneapolis
St. John the Baptist / Savage
St. Jude of the Lake / Mahtomedi
Class Attending
*
Please Select
Infant: 6 Weeks-15 Months
Explorers: 16 - 35 Months
Discovery: 3-4 Years Old
Kinderstart: 4-5 Years Old
Schedule Attending (Days/Times)
*
Student Name (First and Last)
*
Student's Birthdate
*
/
Month
/
Day
Year
Date
Student's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Health Insurance Provider
*
Parent/Guardian 1 Name
*
Parent/Guardian 1 Phone
*
Parent/Guardian 2 Name
*
Parent/Guardian 2 Phone
*
Physician or Health Clinic Name (Required by DHS Licensing)
*
Physician or Health Clinic Phone Number
*
Physician or Health Clinic Address (Required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician or Health Clinic Address
*
Dentist or Dental Clinic Name Dentist lor Dental Clinic Address
*
Dentist or Dental Clinic Name & Address (Required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist or Dental Clinic Phone Number
*
Hospital Preference / Name (Required by DHS Licensing)
*
Hospital Address (Required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
and Address
*
Special Health Needs or N/A (Not Applicable) ie: Allergies, Asthma, Seizures, Orthopedic or Sensory Issues or other Health Needs
*
Medications taken for chronic conditions, if any or N/A (Not Applicable)
*
Dates and Info of Major Illnesses or Injuries since start of last school year, if any or N/A (Not Appplicable):
*
Additional Emergency Contacts / Authorized to Pick-Up:
Three ADDITIONAL EMERGENCY CONTACTS, in addition to parents, are required by DHS Licensing for students to attend.
Emergency Contact#1: NAME (cannot be the parent)
*
RELATIONSHIP to STUDENT
*
Phone of Emergency Contact #1
*
Emergency Contact #1 Address (cannot be parent; required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address and City of Emergency Contact #1
*
Emergency Contact #2: NAME (cannot be the parent)
*
RELATIONSHIP to STUDENT
*
Phone of Emergency Contact #2
*
Emergency Contact #2 Address (cannot be parent; required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address and City of Emergency Contact #2
*
Emergency Contact #3 (cannot be the parent)
*
RELATIONSHIP to STUDENT
*
Phone of Emergency Contact #3
*
Emergency Contact #2 Address (cannot be parent; required by DHS Licensing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address and City of Emergency Contact #3
*
Parent Name
*
Signature
*
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