revised 2024 Student emergency information form

ST. BEDE THE VENERABLE SCHOOL STUDENT EMERGENCY INFORMATION AND AUTHORIZATION
Students Last Name
Family Name if different than students
Address
Phone Number
Format: (000) 000-0000.
City
State
Zip
Childrens Names
Birthdate

MonthDayYear
Date
Grade
Allergiesother med
Childrens Names
Birthdate

MonthDayYear
Date
Grade
Allergies/other med
Childrens Names
Birthdate

MonthDayYear
Date
Grade
Allergiesother med
Childrens Names
Birthdate

MonthDayYear
Date
Grade
Allergiesother med
Fathers Full Name
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Mothers Full Name
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
If unable to contact a parent, who should be contacted?
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
If neither parent can be contacted, I hereby authorize the school to take such emergency measures as necessary. I also acknowledge that I will adhere to the policies in the student/parent handbook (available online)
Parent Signature
Date

MonthDayYear
Date
Should be Empty: