Student Emergency Information Form

In accordance with California Education Code Section 49408, the Los
Angeles Unified School District (LAUSD) requires parents/guardians to
provide current and accurate emergency contact information to the
school of attendance.

Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain students at school for their safety. This form will be used by the school staff when students are released to go home.

Student Name

First NameLast Name

Student First Name

Student Last Name

CHOSEN OR PREFERRED NAME (if different)

Middle Initial

BIRTH DATE

Date

GENDER

GRADE

HOME LANGUAGE

Student Home Address Number

Street Number

Student Home Street Name

APT

City

Zip Code

DO YOU HAVE A SEPARATE MAILING ADDRESS?

Mailing Address - Street Number

Mailing Address - Street Name

APT

CITY

ZIP CODE

Parent/Legal Guardian #1

FIRST NAME LAST NAME

RELATIONSHIP TO STUDENT (Parent/Legal Guardian #1) (i.e. Mother, Father)

Student Lives With Parent/Legal Guardian #1?

WORK ADDRESS - STREET NUMBER (Parent/Legal Guardian #1)

Street Number

STREET NAME

CITY

ZIP CODE

HOME Phone Number (Parent/Legal Guardian #1)

Please enter a valid phone number.Format: (000) 000-0000.

CELL Phone Number (Parent/Legal Guardian #1)

Please enter a valid phone number.Format: (000) 000-0000.

WORK Phone Number (Parent/Legal Guardian #1)

Please enter a valid phone number.Format: (000) 000-0000.

For ATTENDANCE call:

For EMERGENCY call:

For GENERAL INFORMATION call:

I authorize receiving text messages and understand that I am responsible for text related charges.

EMAIL ADDRESS (Parent/Legal Guardian #1)

example@example.com

Parent/Legal Guardian #2

FIRST NAMELAST NAME

RELATIONSHIP TO STUDENT (i.e. Mother, Father)

Student Lives With Parent/Legal Guardian #2?

WORK ADDRESS - STREET NUMBER (Parent/Legal Guardian #2)

Street Number

STREET NAME

CITY

ZIP

HOME Phone Number (Parent/Legal Guardian #2)

Please enter a valid phone number.Format: (000) 000-0000.

CELL Phone Number (Parent/Legal Guardian #2)

Please enter a valid phone number.Format: (000) 000-0000.

WORK Phone Number (Parent/Legal Guardian #2)

Please enter a valid phone number.Format: (000) 000-0000.

For ATTENDANCE Call (Parent/Legal Guardian #2)

For EMERGENCY Call (Parent/Legal Guardian #2)

For GENERAL INFO Call (Parent/Legal Guardian #2)

EMAIL ADDRESS (Parent/Legal Guardian #2)

example@example.com

A unique email address is required for Parent/Guardian #2

I authorize receiving text messages and understand that I am responsible for all text related charges.

To the principal: In case you are unable to reach me during any emergency, you are authorized to contact and, if necessary, release my child to any of the following:

FIRST AND LAST NAME

RELATIONSHIP TO STUDENT

Home

Please enter a valid phone number.Format: (000) 000-0000.

Cell

Please enter a valid phone number.Format: (000) 000-0000.

Work

Please enter a valid phone number.Format: (000) 000-0000.

FIRST AND LAST NAME

RELATIONSHIP TO STUDENT

HOME PHONE

Format: (000) 000-0000.

CELL PHONE

Format: (000) 000-0000.

WORK PHONE

Format: (000) 000-0000.

FIRST AND LAST NAME

RELATIONSHIP TO STUDENT

HOME PHONE

Format: (000) 000-0000.

CELL PHONE

Format: (000) 000-0000.

WORK PHONE

Format: (000) 000-0000.

List any other family members attending Lanai Road Elementary School.

LAST NAME

FIRST NAME

Grade

RELATIONSHIP (Brother, Sister, Cousin)

LAST NAME

FIRST NAME

Grade

RELATIONSHIP (Brother, Sister, Cousin)

MILITARY CONNECTED FAMILY: In efforts to provide resources and support to military connected students and their families, please respond to the following:

Do you have immediate family in the military (Active Duty, Guard, Reserve or Veteran?)

Relationship to Student

Currently Deployed

Military Branch

Status

The undersigned, as parent/legal guardian of, a minor, (ENTER NAME OF STUDENT) First Name* Last Name* hereby authorizes the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and hereby authorizes the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to the Los Angeles Unified School District (“District”) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization is given in accordance with Section 49407 of the California Education Code, and shall remain effective until revoked in writing and delivered to the District. I understand that the District, its officers and its employees assume no liability of any nature in relation to the transportation of the student. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian.

HEALTH ALERTS -- List any medical condition which restricts physical activity or requires special attention. Include conditions such as asthma and allergies such as peanut and bee stings. If none, please indicate “none”.

Does the student have health insurance?

If "yes":

Medi-Cal/Healthy Families ID Number:

1. PRIVATE HEALTH INSURANCE NAME

GROUP NO.

2. Private Health Insurance Name (If covered under more than one plan)

GROUP NO.

NAME OF DOCTOR / MEDICAL OFFICE

PHONE NUMBER OF DOCTOR/MEDICAL OFFICE

Please enter a valid phone number.Format: (000) 000-0000.

*If the student currently does not have health insurance, information on free or low-cost health care programs is available by calling the District’s toll-free HELPLINE 1(866)742-2273.

MY CHILD IS ALLERGIC TO THE FOLLOWING MEDICATIONS:

MY CHILD CURRENTLY TAKES THE FOLLOWING MEDICATIONS

I CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HEREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.

Parent Signature Signature

SIGNATURE OF (check one):

DATE

Date

ERROR: A unique email address must be entered for Parent/Guardian #2

ERROR: A unique Cell Phone Number must be entered for Parent/Guardian #2