Student Health Information

Student Emergency Contact Form

Please fill out the following form for each student enrolled at Harbor House
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Phone

Area CodePhone Number
Emergency Contact 1 Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone

Area CodePhone Number
Emergency Contact 2 Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide details of the physician or health care provider that you would like us to contact in the event of an emergency:
Medical Contact (preferred doctor)

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Medications
Pre-Existing Medical Conditions
I have voluntarily provided the above contact information and authorize you to contact any of the above on my behalf in the event of an emergency.
Emergency Treatment and Transportation Authorization*

Parent/Guardian Signature

Student Emergency Contact Form