Student_Info

Student Contact & Emergency Form

One per family
Student's Name*

First NameLast Name
Student's Date of Birth #1*

MonthDayYear
Date
Student #1 Grade
Student's Name #2

First NameLast Name
Student's Date of Birth #2

MonthDayYear
Date
Student #2 Grade
Student's Name #3

First NameLast Name
Student's Date of Birth #3

MonthDayYear
Date
Student #3 Grade
Student's Name #4

First NameLast Name
Student's Date of Birth #4

MonthDayYear
Date
Student #4's Grade
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child/Children Live with:*

Both ParentsMother as Custodial ParentFather as Custodial ParentFamily Member (with Legal Custody)Other*
*If Other, Please Explain
Check if applicable:

Is there a court order (or pending order) affecting the custody and/or residency of the child?If there is a non-residential parent, do they have visitation rights?Is there a court decision that states that the non-residential parent should NOT receive school information or attend school activities?Is the non-residential parent responsible for paying tuition and fees?
{studentsName} {studentsDate}

{studentsName4} {studentsDate110}

{studentsName5} {studentsDate111}

{studentsName6} {studentsDate112}
Mother/Guardian's Name

First NameLast Name
Mother/Guardian's Email
example@example.com
Mother/Guardian's Cell #
Please enter a valid phone number.
Mother/Guardian's Work #
Please enter a valid phone number.
Father/Guardian's Name

First NameLast Name
Father/Guardian's Email
example@example.com
Father/Guardian's Cell #
Please enter a valid phone number.
Father/Guardian's Work #
Please enter a valid phone number.

Contact in case of emergency & the parent/guardian is not available:
Contact #1*

First NameLast Name
#1 Relationship to Student*
#1 Phone Number*
Please enter a valid phone number.
#1 Authorized to Pick Up*

YesNo
Contact #2*

First NameLast Name
#2 Relationship to Student*
#2 Phone Number*
Please enter a valid phone number.
#2 Authorized to Pick Up*

YesNo
Contact #3*

First NameLast Name
#3 Relationship to Student*
#3 Phone Number*
Please enter a valid phone number.
#3 Authorized to Pick Up*

YesNo
Is there anyone whom you do not want to have your child released to?*

{studentsName} & {studentsDate}

{studentsName4} & {studentsDate110}

{studentsName5} & {studentsDate111}

{studentsName6} & {studentsDate112}
Part 1 or Part 2 must be completed
Part 1
Preferred Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Preferred Dentist's Name
Dentist's Phone Number
Please enter a valid phone number.
Preferred Hospital
Part 2

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to:
Briefly state acceptable actions for your child
Parent/Guardian Signature*

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Today's Date*

MonthDayYear
Date
Should be Empty:

Student Contact & Emergency Form

Contact in case of emergency & the parent/guardian is not available:

Part 1 or Part 2 must be completed

Part 1

Part 2