ELE/MID EMERGENCY CONTACT FORM

EMERGENCY CONTACT FORM
FAMILY INFORMATION
Name of Parent/Guardian #1

First NameLast Name
Relationship to child:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Work Phone
Email
example@example.com
Name of Parent/Guardian #2

First NameLast Name
Relationship to child:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Work Phone
Email
example@example.com
CHILD INFORMATION
Name of Student #1

First Name & MiddleLast Name
MaleFemale
Date of Birth

MonthDayYear
Emergency Contact Name
Emergency Contact Phone #
Authorized Pick Up Person #1
Phone #
CHILD INFORMATION
Name of Student #2

First Name & MiddleLast Name
MaleFemale
Date of Birth

MonthDayYear
Emergency Contact Name
Emergency Contact Phone #
Authorized Pick Up Person #1
Phone #
Authorized Pick Up Person #2
Phone #
Authorized Pick Up Person #3
Phone #
Known Allergies
Date

MonthDayYear
Date
Authorized Pick Up Person #2
Phone #
Signature of Parent or Legal Guardian

Clear
Authorized Pick Up Person #3
Phone #
Known Allergies
Date

MonthDayYear
Date
8. EMERGENCY CARE AUTHORIZATION

I certify that I am a parent or legal guardian of the child or children named above and give consent for emergency medical care, surgical treatment, and/ or transportation to a care facility should my child’s condition require it in my absence. I understand that, time and conditions permitting, reasonable attempts will first be made to contact me and any designated representatives in such a case. I hereby assume all financial responsibility for such actions taken on behalf of my child.
Date

MonthDayYear
Date
Adding or removing information on the emergency contact form will be allowed only by parents or guardian. If changes are necessary the form will need to be completed again with no option for correction once submitted.
Should be Empty: