ACS Emergency Contact & Identification Information Form 2024-2025

ANANSI CHARTER SCHOOL
EMERGENCY CONTACT AND IDENTIFICATION INFORMATION
Child's name*
Birthdate*

MonthDayYear
Date
Grade*
Parent or Guardian's Name #1*
Home Address*
City*
State*
Zip Code*
Home Phone #1*
Cell Phone #1*
Work Address #1
City
State
Zip Code
Work Phone
Parent or Guardian's Name #2
Home Address #2 (if applicable)
City #2
State #2
Zip Code #2
Home Phone #2
Cell Phone #2
Work Address #2
City
State
Zip Code
Work Phone #2
II. Names of Persons authorized to take child from Anansi Charter School (This child will not be allowed to leave with any other person without written authorization from parent or guardian.)
AUTHORIZED PERSON'S NAME*
ADDRESS
AUTHORIZED PERSON'S PHONE*
RELATIONSHIP
AUTHORIZED PERSON'S NAME
ADDRESS
AUTHORIZED PERSON'S PHONE
RELATIONSHIP
III. Additional persons who may be called in an Emergency to take your child from Anansi Charter School:
EMERGENCY CONTACT'S NAME*
ADDRESS
EMERGENCY CONTACT'S PHONE*
RELATIONSHIP
EMERGENCY CONTACT'S NAME
ADDRESS
EMERGENCY CONTACT'S PHONE
RELATIONSHIP
IV Name of Physician to be called in an Emergency*
Physician's Address
Phone*
If physician cannot be reached, what action should be taken?
V Medical Insurance Carrier*
Policy #:
Is this Medicaid?

YesNo
Medicaid Number
Does your child have allergies or other medical limitation:*
II. Permission for Medical Treatment: Administration procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the absence of the parent/guardian. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance.

In case of an accident or an emergency, I authorize a staff member of Anansi Charter School to take my child to the above named physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child, at my expense.
Signature*

Clear
PRINTED NAME OF PARENT/GUARDIAN OF CHILD*
Should be Empty:

ANANSI CHARTER SCHOOL

EMERGENCY CONTACT AND IDENTIFICATION INFORMATION