Emergency Information Sheet
STUDENT'S NAME
GRADE
ADDRESS
CITY
ZIP
PARENT'S/GUARDIAN'S NAME:
FATHER:
CELL PHONE:
Format: (000) 000-0000.
EMAIL:
example@example.com
PLACE OF WORK:
PHONE
Format: (000) 000-0000.
MOTHER:
CELL PHONE:
Format: (000) 000-0000.
EMAIL:
example@example.com
PLACE OF WORK:
PHONE
Format: (000) 000-0000.
MY CHILD:
MAY
MAY NOT
HAVE TYLENOL IF NEEDED.
MY CHILD:
MAY
MAY NOT
HAVE IBUPROFEN IF NEEDED.
LIST ALLERGIES TO MEDICATIONS/FOODS.
FAMILY PHYSICIAN:
ADDRESS
PHONE #
Format: (000) 000-0000.
IN CASE OF EMERGENCY, I GIVE PERMISSION FOR CORNERSTONE CHRISTIAN ACADEMY TO HAVE MY CHILD TRANSPORTED TO THE NEAREST MEDICAL FACILITY.
SIGNATURE
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MY CHILD MAY BE RELEASED TO THE FOLLOWING:
NAME
PHONE
Format: (000) 000-0000.
NAME
PHONE
Format: (000) 000-0000.
NAME
PHONE
Format: (000) 000-0000.
NAME
PHONE
Format: (000) 000-0000.
NAME
PHONE
Format: (000) 000-0000.
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