Emergency Contact Form -

2017-2018 Emergency Contact Information and Treatment Authorization

Student Information
Name*
First Last
Birthday*
MM slash DD slash YYYY
Grade*
Student District
Student Medical Information
Does the student have significant allergies?*
- Yes
- No
Describe Allergies
Describe treatments/medicines your child needs to take while at school, etc.
Describe any known medical conditions requiring special attention
Child's Doctor:
Doctor's Phone
Parent/Guardian1 Information
Parent/Guardian1 Name*
First Last
Parent/Guardian1 Email*
Parent/Guardian1 Home Phone
Parent/Guardian1 Cell Phone
Parent/Guardian1 Work Phone
Parent/Guardian1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian2 Information
Parent/Guardian2 Name
First Last
Parent/Guardian2 Email
Parent/Guardian2 Home Phone
Parent/Guardian2 Work Phone
Parent/Guardian2 Cell Phone
Same Address as Above*
- Yes
- No
Parent/Guardian2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alternate Contact 1
Name
First Last
Phone
Email
Relationship
Alternate Contact 2
Name
First Last
Email
Phone
Relationship

-- OR -- Login using your gmail account below ---