St. Anselm School - Emergency Contact Information Card

2022-2023
UNIVERSAL MEDICAL INFORMATION/EMERGENCY CONTACT
RELEASE AND CONSENT FORM
School
School Year
Name of Student (Last,First, Middle)*
Grade
Teacher Name
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Email Address
example@example.com
Siblings at school
Name
Grade
Teacher
Name
Grade
Teacher
Name
Grade
Teacher
Is child living with both Parents/Guardians?
Parent/Guardian Name

First NameLast Name
Parent/Guardian Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Home Address (if different from child’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Home Phone (If different from child’s):
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Guardian Work Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Home Address (if different from child’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Home Phone (If different from child’s):
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email*
example@example.com
Parent/Guardian Work Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts - your signature (*) authorizes these people to pick up your child from school:
Name 1
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Name 2
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Name 3
Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number 3
Please enter a valid phone number.Format: (000) 000-0000.
Name 4
Address 4

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number 4
Please enter a valid phone number.Format: (000) 000-0000.
Signature

Clear
Relationship to child
Student Medical Information:

Primary Physician:
Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Physician:
Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Conditions: (e.g., diabetes, epilepsy, heart conditions, etc.)
Disabilities
Allergies: (e.g., hay fever, strawberries, peanuts, etc.)
Medications:
Allergies to Medications:
Should be Empty:

Student Medical Information: