Emergency/Earthquake Form
2025-2026
Student Name
First Name
Last Name
Student Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Grade
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name #1
First Name
Last Name
Parent/Guardian #1 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name #2
First Name
Last Name
Parent/Guardian #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency name for local contact and relationship
Phone number for emergency local contact
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency name for out-of-state contact and relationship
Phone number for emergency out-of-state contact
Please enter a valid phone number.
Format: (000) 000-0000.
Name(s) of person(s) authorized to pick up student in an emergency
Please list any student allergies (food, pet, insect, drug, latex, pollen, etc.)
Please check all conditions that apply to your child and give a brief explanation/instructions below.
Asthma
ADHD
Blood disease
Diabetes
Epilepsy/Seizures
Anxiety/Depression
Frequent headaches
Frequent stomachaches
Frequent nosebleeds
Glasses/Contacts
Hearing impairment
Heart abnormality
Nervousness
Physical disability
Other
Explanation/Special Instructions:
Does your child take regular medication?
Yes (please list below)
No
If you answered yes above, please list the medication and dosage:
Submit
Should be Empty: