Emergency Care Card (Form 5160)

CATHOLIC SCHOOL SYSTEM OF THE ARCHDIOCESE OF ATLANTA STUDENT EMERGENCY CARE FORM
Student Name*

First NameLast Name
Student Middle Name Initial*
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Grade*
Father's Name*

First NameLast Name
Father's Address*

Address

Street Address Line 2

CityState / Province

Zip
Father's Phone Number*
Please enter a valid phone number.
Father's Work Phone Number*
Please enter a valid phone number.
Father's Cell Phone Number*
Please enter a valid phone number.
Father's Workplace / Name of Business*
Mother's Name*

First NameLast Name
Mother's Address

Address

Street Address Line 2

CityState / Province

Zip
Mother's Home Phone Number*
Please enter a valid phone number.
Mother's Work Phone Number*
Please enter a valid phone number.
Mother's Cell Phone Number*
Please enter a valid phone number.
Mother's Workplace / Name of Business*
Person(s) To Call In Emergency When Parents Cannot Be Reached / and who may pick up the child from school
Emergency Contact #1
Full Name*

First NameLast Name
Relationship*
Phone*
Emergency Contact #2
Full Name

First NameLast Name
Relationship
Phone
Emergency Contact #3
Full Name

First NameLast Name
Relationship
Phone
Health
Family Physician*
City*
Phone*
Choice of Hospital:*
Insurance Company:*
Has child any drug/food/environmental/etc. allergies?*
Any additional medical information:*
List daily medications:*
Date of latest TD*

MonthDayYear
Date
If any emergency arises, the school will try to contact the student's mother or father If neither parent can be reached, I give permission to Dr.*
Name of Doctor
to be wholly responsible for the care of my child. If he is unavailable in the event of a major emergency, the administration is directed to seek emergency care at the medical or hospital facility indicated above. I will be responsible for the payment of all expenses incurred.
Please print and sign. A digital signature is not acceptable, per Archdiocesan policy.
Should be Empty:

CATHOLIC SCHOOL SYSTEM OF THE ARCHDIOCESE OF ATLANTA STUDENT EMERGENCY CARE FORM

Person(s) To Call In Emergency When Parents Cannot Be Reached / and who may pick up the child from school

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Health

Please print and sign. A digital signature is not acceptable, per Archdiocesan policy.