Student Emergency Form


Last Name:                                                            First Name:                                                                   

Date of Birth:                        Grade:                      Homeroom teacher:                                                 _
Address:                                                                               Home Phone:     ______________       
Father's Name:                                                       Mother's Name:                        __________     
Father's Employer:                                                  Mother’s Employer:                   __________    
Work#:                                     Work#:                          ______________       

Father's cell phone:                                                _ Mother's cell phone:                                               _

If  am not available in case of an illness or emergency, I have made arrangements with the persons listed below to care for my child:

Name:                                                        Relationship:                                          Phone#:         ______   
Name:     _________________________ 
Relationship    __________________Phone#:         ______   

Family Physician:                                                      Phone#:                                                                       


To  Parent or Guardian:

The welfare of your child is the first consideration of school authorities. When in the case of serious medical emergency or illness and the school is unable to contact parent, guardian or authorized physician immediately, the school may call an ambulance or make whatever arrangements seem necessary without involving the school in any financial obligation. It is your responsibility to make arrangements for proper care in case your child should meet with an accident or become too ill in school at a time when you are away from home. Please assist by;

  1. Providing transportation home or to the doctor's office if necessary.
  2. Designating a neighbor or relative to provide transportation and care for your child in their home until you can be reached.
  3.  Notify the school immediately should you have any changes in your address, phone number, or place of employment.

Please read the attached information regarding the Epipen for treatment of severe life threatening allergic reactions and indicate  your choice below.  

Administer Epipen for life threatening allergic  reaction?

Yes            No___

I have read the information on this card and agree to all of the conditions listed.

Date:                                     Parent/Guardian Signature: