General, Emergency Contact & Evacuation Information, 2021/22
Child’s Name: ________________________________________________________________________________ Date of Birth: _________________________
Physical Address: ______________________________________________________________________________________________________________________
Street City State Zip code
Mailing Address: _______________________________________________________________________________________________________________________
Street City State Zip code
Residence/Subdivision/Neighborhood Location: ___________________________________ Email: _____________________________________________
Parent/Guardian: ________________________________________________________________________________________________________________________
Name Home Phone
________________________________________________________________________________________________________________________
Work Phone Cell Phone Email Address
Parent/Guardian: ________________________________________________________________________________________________________________________
Name Home Phone
________________________________________________________________________________________________________________________
Work Phone Cell Phone Email Address
We always try to contact parents first. However, we are
required to have an emergency contact other than parents. In the event of a
medical, emotional, and/or disciplinary emergency and you cannot be reached; the following person/s may be contacted to assume
responsibility in your absence (more spaces on back).
___________________________________________________________________________________________________________________________________________
Name Relation to Student Home Phone Cell Phone
___________________________________________________________________________________________________________________________________________
Name Relation to Student Home Phone Cell Phone
Other people authorized to pick up my child in non-emergency situations, like carpools, play dates, etc. (more spaces on back):
___________________________________________________________________________________________________________________________________________
Name Relation to Student Home Phone Cell Phone
___________________________________________________________________________________________________________________________________________
Name Relation to Student Home Phone Cell Phone
Grandparent(s): ________________________________________________________________________________________________________________________
Name(s) Address
________________________________________________________________________________________________________________________
Home/Cell Phone Email
Grandparent(s): ________________________________________________________________________________________________________________________
Name(s) Address
________________________________________________________________________________________________________________________
Home/Cell Phone Email
We are
required to have your permission to contact and/or deliver your child to their physician or nearest clinic/hospital. Please
provide the facilities and locations with address and phone numbers here.
Child’s physician/clinic: __________________________________________________________________________________________________________________
Name Address Phone
Hospital/Clinic: __________________________________________________________________________________________________________________________
Name Address Phone
Health Insurance Provider: ________________________________________________ Subscriber #: ______________________________________________
*Allergies, dietary restrictions, medical needs/precautions (do not leave blank):
________________________________________________________________________________________________
