Emergency Information Form Emergency Information Form Student Last Name * Student First Name * Student Middle Name Grade K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade SSN * Date of Birth * Phone Number * Address * City * State * Zip Code * Mother/Guardian Last Name * Mother/Guardian First Name * Mother/Guardian Cell Phone Number Father/Guardian Last Name * Father/Guardian First Name * Father/Guardian Cell Phone Number Email * Relative 1 Last Name * Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 1 First Name * Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 1 Phone Number * Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 1 Relationship * Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 2 Last Name Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 2 First Name Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 2 Phone Number Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 2 Relationship Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 3 Last Name Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 3 First Name Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 3 Phone Number Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Relative 3 Relationship Nearby relatives or neighbors who will assume temporary care of your child if you cannot be reached: Name of Parent / Guardian * In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the Physician indicated below and to follow his/her instruction. If it is impossible to contact this Physician, the school may do what the feel is medically necessary. Date * In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the Physician indicated below and to follow his/her instruction. If it is impossible to contact this Physician, the school may do what the feel is medically necessary. Signature of Parent / Guardian * In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the Physician indicated below and to follow his/her instruction. If it is impossible to contact this Physician, the school may do what the feel is medically necessary. Name of Parent / Guardian * The recommended dosage will be administered as specified on the bottle unless given different written dosage by Parent/ Guardian. Date * The recommended dosage will be administered as specified on the bottle unless given different written dosage by Parent/ Guardian. Signature of Parent / Guardian * The recommended dosage will be administered as specified on the bottle unless given different written dosage by Parent/ Guardian. The following medications may be given * Tylenol Aspirin Sudafed Neosporin Tums Benadryl Midol Ibuprofen Hydrocortisone Cough Drop None of the above The following medications may NOT be given * Tylenol Aspirin Sudafed Neosporin Tums Benadryl Midol Ibuprofen Hydrocortisone Cough Drop None of the above Local Physician’s Name * Local Physician’s Address * Local Physician’s Office Phone Number * Local Physician’s Fax Number * If you are human, leave this field blank. Submit
