Emergency Contact & Physician Info — 2026–2027
Add updated emergency contacts and your child’s physician details (about 2 minutes) for each student.
Student's Full Name
*
First Name
Last Name
Student's Program
*
The Robins (Ages 5-7)
The Hummingbirds (Ages 6-8)
The Owls (Ages 7-9)
The Hawks (Ages 8-10)
The Eagles (Ages 9-12)
Parent/Guardian Completing This Form — Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email
*
example@example.com
Second Parent/Guardian Name and Phone
Emergency Contacts
Emergency Contact #1 — Full Name
*
First Name
Last Name
Emergency Contact #1 — Relationship to Student
*
Emergency Contact #1 — Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is Emergency Contact #1 authorized to pick up your child?
*
Yes
No
Emergency Contact #2 — Full Name
First Name
Last Name
Emergency Contact #2 — Relationship to Student
Emergency Contact #2 — Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is Emergency Contact #2 authorized to pick up your child?
Yes
No
Medical Information
Child's Physician or Pediatric Practice — Name
*
Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital or Urgent Care
Health Insurance Carrier and Policy/Member Number
Allergies, medical conditions, or medications RCS staff should know about
Include anything staff should watch for and any action to take. If none, write 'None.' This does not replace anything you told us at enrollment — it's a chance to update us.
I authorize Roseville Community School staff to contact the people listed above and to seek medical treatment for my child if I cannot be reached in an emergency. I understand every effort will be made to reach me first.
*
I agree
Submit
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