Emergency Contact Form
2025-2026 School Year
Student #1 Name
First & Middle
Last
Student #1 DOB
-
Month
-
Day
Year
Date
Student #1 Grade Level (2025-2026 Academic Year)
Please Select
pre-K
K
1
2
3
4
5
6
7
8
Student Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student #2 Name
First & Middle
Last
Student #2 DOB
-
Month
-
Day
Year
Date
Student #2 Grade Level (2025-2026 Academic Year)
Please Select
pre-K
K
1
2
3
4
5
6
7
8
Student #3 Name
First & Middle
Last
Student #3 DOB
-
Month
-
Day
Year
Date
Student #3 Grade Level (2025-2026 Academic Year)
Please Select
pre-K
K
1
2
3
4
5
6
7
8
Student #4 Name
First & Middle
Last
Student #4 DOB
-
Month
-
Day
Year
Date
Student #4 Grade Level (2025-2026 Academic Year)
Please Select
pre-K
K
1
2
3
4
5
6
7
8
Student #5 Name
First & Middle
Last
Student #5 DOB
-
Month
-
Day
Year
Date
Student #5 Grade Level (2025-2026 Academic Year)
Please Select
pre-K
K
1
2
3
4
5
6
7
8
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Next
Authorized Individual
Name of Individual Completing Form
First Name
Last Name
Relationship to student(s)
Mother
Father
Legal Guardian
Other
If "other," please explain
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Next
Mother/Guardian Information
Name
First & Middle
Last
Employer/Company
Cell Phone Number
Please enter a valid phone number.
Work or Alternate Number
Please enter a valid phone number.
Email
example@example.com
Home Address (if different from student)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother/Guardian Permissions (check all that apply)
Lives with Child
Custodial Rights
Send Mail Home
Authorized Emergency Contact
Print Name on Reports
Authorized for Pick-up
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Next
Father/Guardian Information
Name
First & Middle
Last
Employer/Company
Cell Phone Number
Please enter a valid phone number.
Work or Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Home Address (if different from student)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father/Guardian Permissions (check all that apply)
Lives with Child
Custodial Rights
Send Mail Home
Authorized Emergency Contact
Print Name on Reports
Authorized for Pick-up
Back
Next
Parent/Guardian Information
Please make sure to submit ANY necessary legal paperwork
Is there a visitation order or other court order banning any individual from removing the student during the school day or coming into contact with the student during the school day?
Yes
No
Do parents have shared parental responsibility via court proceedings or order?
Yes
No
Anyone who should NOT BE ALLOWED to pick your student up from school?
First Name
Last Name
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Next
Residency
Student County of Residence
*Main residence
School Corporation of Residence
Public School of Residence
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Next
Individual Student Concerns
Please provide SPS with any documentations associated with "yes" responses
Does student #1 have in place an IEP, ISP, CSEP?
Yes
No
Does student #1 have any medical concerns (asthma, diabetes, seizures, etc.)?
Yes
No
Known allergies of student #1
Please list any medications student #1 takes on a regular or prescribed basis.
Does student #2 have in place an IEP, ISP, CSEP?
Yes
No
Does student #2 have any medical concerns (asthma, diabetes, seizures, etc.)?
Yes
No
Known allergies of student #2
Please list any medications student #2 takes on a regular or prescribed basis.
Does student #3 have in place an IEP, ISP, CSEP?
Yes
No
Does student #3 have any medical concerns (asthma, diabetes, seizures, etc.)?
Yes
No
Known allergies of student #3
Please list any medications student #3 takes on a regular or prescribed basis.
Does student #4 have in place an IEP, ISP, CSEP?
Yes
No
Does student #4 have any medical concerns (asthma, diabetes, seizures, etc.)?
Yes
No
Known allergies of student #4
Please list any medications student #4 takes on a regular or prescribed basis.
Does student #5 have in place an IEP, ISP, CSEP?
Yes
No
Does student #5 have any medical concerns (asthma, diabetes, seizures, etc.)?
Yes
No
Known allergies of student #5
Please list any medications student #5 takes on a regular or prescribed basis.
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Next
Medical Treatment Release
Primary Doctor
Phone Number of Primary Doctor
Please enter a valid phone number.
Dentist
Phone Number of Dentist
Please enter a valid phone number.
Insurance Carrier
Hospital Preference
I give St. Patrick School of the Terre Haute Deanery and its designated representative permission to transport and sign all forms related to the necessary medical treatment for my child.
Yes
No
I permit any and all required medical treatment to be administered by qualified medical personnel, including calling 9-1-1.
Yes
No
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Next
Emergency Contact Information
Please list individuals (in preference order) to contact if parents/guardians are unavailable
Emergency Contact #1
First Name
Last Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Emergency Contact #2
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Submit
Should be Empty: