CMHS Student Emergency Card

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Student's LAST Name: *

Student's FIRST Name: *

Student's MIDDLE Name: *

Student's Address *

Date of Birth *

YYYY

Grade *

Required

Student resides with (include siblings) *

Parent/Guardian #1 LAST Name *

Parent/Guardian #1 FIRST Name *

Parent/Guardian #1 Email *

Parent/Guardian #1 Address (if different than student's)

Parent/Guardian #1 HOME Phone # *

Parent/Guardian #1 CELL Phone #

Parent/Guardian #1 WORK Phone #

Parent/Guardian #2 LAST Name *

Parent/Guardian #2 FIRST Name *

Parent/Guardian #2 Email *

Parent/Guardian #2 Address (if different than student's)

Parent/Guardian #2 HOME Phone # *

Parent/Guardian #2 CELL Phone #

Parent/Guardian #2 WORK Phone #

Emergency Contact #1 (other than parents, NAME, RELATIONSHIP and PHONE #) *

Emergency Contact #2 (other than parents, NAME, RELATIONSHIP and PHONE #)

Emergency Contact #3 (other than parents, NAME, RELATIONSHIP and PHONE #)

Please list Medical Conditions, Allergies and/or Medications: If needed, please fill out the followig forms: Medication Authorization Form , Allergy Action Plan *

Consent for Emergency Room Treatment *

YES

I give permission for my child to receive an Epi-Pen in the event of a Life-Threatening Allergic Reaction *

YES

NO (Policy #210-AR) ~ If left blank it is assumed you are NOT opting out

Parent/Guardian Signature *

I confirm that the information given in this form is true, complete and accurate.

Required

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