Emergency/Earthquake Form
2026-2027
Student Name
First Name
Last Name
Student Date of Birth
-
Month
-
Day
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 Phone #1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email #1
*
example@example.com
Parent/Guardian Name #2
First Name
Last Name
Parent/Guardian Phone #2
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email #2
example@example.com
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
Severe Allergy (one requiring EpiPen)
N/A
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: