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
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
Work Phone Number
Mothers Full Name
Cell Phone Number
Work Phone Number
If unable to contact a parent, who should be contacted?
Name
Relationship
Phone Number
Name
Relationship
Phone Number
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

Clear
Date

MonthDayYear
Date
Should be Empty: