Emergency Information Form

Your Child's Name(Required)

First Last

Date of Birth(Required)

School Year(Required)

Allergic To:

Click the "+" button to add more rows.

Daily Medications:

Click the "+" button to add more rows.

Please Select All That Apply(Required)

Hearing Impaired

Hearing Aid

Visually Impaired

Glasses/Contacts

Any Other Medical Info:

Child's Physician

Physician's Phone

Physician's Address

Child's Dentist

Dentist's Phone

Dentist's Address

Mother's Name(Required)

First Last

Mother's Employer

Mother's Phone

Father's Name

First Last

Father's Employer

Father's Phone

Person Authorized to Pick Up Child From School Daily

Authorized Person's Phone

When parents cannot be reached, list one person who may be contacted in an emergency.

Relationship

Emergency Person's Phone

Your Digital Signature(Required)

Type Your Name