Emergency Contact Information

Student Emergency Contact Information 2020-2021

Please complete all required fields. You are required to indicate at least one emergency contact person.

* Indicates required field

Student Information

Student Name *

First

Last

Student Date of Birth

Select Month *

Select Day *

Select Year *

Student Phone Number *

Grade Level *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Insurance Carrier *

Primary Doctor's Name and Phone Number *

List any allergies or illnesses that will need our attention: *

Do you authorize the school to give your child over the counter medications like Children’s Tylenol, Children’s Motrin, Children’s Benadryl and/or Pepto Bismol when and if deemed necessary? *

Describe any particular family situation you would like for us to be aware of (divorce, deceased or ill close family member, troubled past experiences, newborn sibling, etc.)? *