2024 Emergency Card Information

Last Name*

First/Middle Name*

Student ID Number

D.O.B.*

Grade*

Ethnicity: Is the student of Hispanic, Latino or Spanish origin?*

YesNo

Race (Check appropriate race(s).*

Home Phone*

Best Phone# to contact*

Address*

City*

State*

Zip Code*

Parent/Guardian*

Employed By*

Work Phone*

Cell Phone*

E-mail Address*

example@example.com

Parent/Guardian

Employed By

Work Phone

Cell Phone

E-mail Address

example@example.com

Additional individuals who will care for child in case a parent/guardian cannot be reached: These individuals may sign my child out (Photo ID required)

Name*

Relationship*

Phone*

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

First and Last names of siblings attending Athenian Academy

Person(s) who MAY NOT legally contact or remove my child from school (Provide Legal Documentation)

It is the Parent/Guardian’s responsibility to keep the school updated with new information and contact numbers.

Parent Bill of Rights
Athenian Academy of Technology and the Arts provides various health services screenings. This means that your child will receive vision, hearing, scoliosis, and blood pressure screening at certain grade levels. In addition, there is a health unit in 6th, 7th, and 8th grade science on health issues such as abstinence, substance abuse prevention, dating and relationship issues, birth control, and sexually transmitted diseases at certain grade levels. If you object to any of these health screenings or programs, you must notify the school in writing by completing the opt-out form on our website. Please refer to our Parent Bill of Rights form on our website for additional information about services and opting out: https://www.aaota.org/wp-content/uploads/2023/05/Parents-Bill-of-Rights.pdf.

In case of an accident or serious illness, you will be contacted by the school. If the school is unable to reach you, you authorize the school to contact the physician or dentist indicated below and to follow his/her instructions. If it is impossible to contact this physician or dentist, the school will take whatever actions are necessary to provide care and treatment for your child, and exchange medical information with the provider as necessary to support the continuity of care for your child. You agree to pay all expenses incurred by handling any emergency care. In case of an accident or illness where immediate treatment of your child is not indicated, but where he/she is unable to remain at school, you request that one of the person(s) listed above be contacted and requested to care for my child until you can be reached.

List of any medication(s) your child is currently taking

List any health problem(s) or allergies of which the school should be aware of

Does your child’s health problem(s) impact his/her learning ability?

YESNo

If Yes, please explain

Physician's Name/Phone

Hospital Preference/Phone

Dentist's Name/Phone

If my child is covered by Medicaid and receives health services under IEP/TIEP, I consent for the school to bill Medicaid for those services.

Current Medicaid Card?

YESNo

Medicaid Number

Parent/Guardian (Print)*

My signature indicates my parental consent, understanding, and agreement.*

Parent/Guardian (Signature)

Date*

Date

EMERGENCY INFORMATION CARD

Student Information

Parent/Guardian Information

Parent/Guardian Information