Emergency Information Form Student InfoYour Child's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY School Year(Required) Allergic To: Add RemoveClick the "+" button to add more rows.Daily Medications: Add RemoveClick 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 PhonePhysician's Address Child's Dentist Dentist's PhoneDentist's Address Guardian InfoMother's Name(Required) First Last Mother's Employer Mother's PhoneFather's Name First Last Father's Employer Father's PhonePerson Authorized to Pick Up Child From School Daily Authorized Person's PhoneWhen parents cannot be reached, list one person who may be contacted in an emergency. Relationship Emergency Person's PhoneConsent(Required) I agreeIn the event of an emergency requiring immediate medical attention, my child may be taken to the NEAREST EMERGENCY ROOM. My digital signature authorizes the school to have my child transported to the emergency room and for the necessary emergency treatment to be given.Your Digital Signature(Required) Type Your Name
