Emergency Information

 

Please fill out completely.  If there is any change in this information, please contact the school immediately.

 

Name of Student:  __________________________________________________________________________________________________

 

Address:  ________________________________________________   City:  _____________________________ Zip:  _________________

 

Home Phone:   (         ) _________  - ____________   Mobile Phone:  (         ) _________  - ______________

 

Age:  _______________       Date of Birth:  _________________            Grade:  ___________________

   

Father’s Name: _______________________________________  Mother’s Name: _______________________________________________

 

Father’s Work #: (         ) _________  - __________   Mother’s Work #: (         ) _________  - ___________

 

 

Legal Guardian:  _________________________________________________ Student Resides with:  Parent      Father   

                                                                                                                                                                                                                       Guardian Mother  

 

In case of emergency, illness, or accident, the school is authorized to call contacts listed:

 

Name: _______________________________________  Phone: (         ) _________  - ____________  Relation:________________________

 

Name: _______________________________________  Phone: (         ) _________  - ____________  Relation:________________________

 

 Name: ______________________________________   Phone: (         ) _________  - ____________  Relation:_______________ ________

 

 

Signature of Parent / Guardian:  ______________________________________________________________  Date:  ______/______/______