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2023-2024 PS 46 - Blue Card - Emergency Contact info
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Please complete the following information below. Please notify the main office and your child's teacher if you ever need to make any changes or updates.
Email
*
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student Class
*
Choose
New Registration
3K 126 Ms. Deng
Pre-K 102 Ms. Nissen
Pre-K 100 Ms. Kaplan
K-129 Ms. DellaRatta
K-118 Ms. Rosenblatt/Ms. Vukic
K-129 Ms. Venier/ Ms. Zickmund
K-128 Ms. Baez
K-2 229 Ms. Russum
1-131 Ms. Monaco
1-130 Ms. Schwartz
1-224 Ms. Gravanis/Ms. Schussel
1-232 Ms. Ronacher
2-228 Ms. Panlilio
2-230 Ms. Frey/ Ms. Mazara
2-227 Ms. Suk
3-206 Mr. Ramoutar
3-202 Ms. Rizzotti/ Ms. Capone
3-200 Ms. Russo/Ms. Arsenis
3-5 231 Ms. Solomon
4-327 Ms. LaCast
4-328 Ms. Rodriguez
4-225 Ms. Falco/ Ms. Maturo
4-325 Ms. Eckersall
5-326 Mr. Marino
5-322 Ms. Matthews/Ms. Alvarado
5-324 Ms. Richter/ Ms. Germano
5-323 Ms. Cheng
3-330 Ms. Ree
Date of Birth of Student (mm/dd/yyyy)
*
MM
/
DD
/
YYYY
Gender of Student
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Male
Female
Does the student have health insurance?
*
Yes
No
Would you like to be contacted about getting health insurance coverage?
*
Yes
No
PARENT / GUARDIAN INFORMATION
For parent 1, please provide the information of a parent/guardian with whom the student resides.
Last Name of Parent 1
*
Your answer
First Name of Parent 1
*
Your answer
Relationship of Parent 1 (e.g., mother, father)
*
Your answer
Cell Phone Number of Parent 1
*
Your answer
Work Phone of Parent 1
Your answer
Email of Parent 1
*
Your answer
Preferred Written Language of Parent 1
*
English (English)
Chinese
Korean
Spanish
Other:
Preferred Spoken Language of Parent 1
*
English (English)
Chinese
Korean
Spanish
Other:
Home Address of Parent 1 (house number, street, apt, city)
*
Your answer
Zip Code of Parent 1 Address
*
Your answer
Is this a new address for the student (different from what we have on record)?*
*
Yes
No
OTHER PARENT/GUARDIAN INFORMATION
Last Name of Parent 2
Your answer
First Name of Parent 2
Your answer
Relationship of Parent 2 (e.g., mother, father)
Your answer
Cell Phone Number of Parent 2
Your answer
Work Phone Number of Parent 2
Your answer
Preferred Written Language of Parent 2
English
Chinese
Korean
Spanish
Other:
Clear selection
Preferred Spoken Language of Parent 2
English
Chinese
Korean
Spanish
Other:
Clear selection
Home Address of Parent 2 (house number, street, apt, city)
Your answer
Zip Code of Parent 2 Address
Your answer
OTHER EMERGENCY CONTACTS - List below names of additional persons who may be called in case of emergency or if child is sick in school. CHILD WILL ONLY BE RELEASED TO PERSONS NAME HERE OR ON THE EMERGENCY CONTACT CARD.
Name of Emergency Contact 1
*
Your answer
Phone Number of Emergency Contact 1
*
Your answer
Relationship to Student of Emergency Contact 1
*
Your answer
Name of Emergency Contact 2
*
Your answer
Phone Number of Emergency Contact 2
*
Your answer
Relationship to Student of Emergency Contact 2
*
Your answer
Name of Emergency Contact 3
*
Your answer
Phone Number of Emergency Contact 3
*
Your answer
Relationship to Student of Emergency Contact 3
*
Your answer
STUDENT HEALTH INFORMATION
Name of Physician/Clinic
*
Your answer
Physician/Clinic Phone Number
*
Your answer
Does child have any health condition that may affect participation in physical activities?
*
Yes
No
Limitations (e.g., stair climbing, participation in gym
*
None
Other:
Allergies*
*
None
Other:
504 services for the current year
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Yes
No
504 services for the previous year
*
Yes
No
If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?
It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent as indicated here will be respected as far as possible.
*
Your answer
NO ACCESS
IF there is a person who may NOT HAVE ACCESS to this child, please indicate that here.
Name of Person with NO Access
Your answer
Relationship of Person with NO Access
Your answer
Order of Protection Exists Against This Person?
Yes
No
Clear selection
STUDENT'S SIBLINGS
Last Name of Sibling 1 (if any)
Your answer
First Name of Sibling 1 (if any)
Your answer
What is the relationship of Sibling 1?
Older Sister
Older Brother
Younger Sister
Younger Brother
Clear selection
School of Attendance for Sibling 1 (if any)
Your answer
Last Name of Sibling 2 (if any)
Your answer
First Name of Sibling 2 (if any)
Your answer
What is the relationship of Sibling 2?
Your answer
School of Attendance for Sibling 2 (if any)
Your answer
Last Name of Sibling 3 (if any)
Your answer
First Name of Sibling 3 (if any)
Your answer
What is the relationship of Sibling 3?
Choose
Older sister
Younger sister
Older Brother
Younger Brother
School of Attendance for Sibling 3 (if any)
Your answer
Please use this area to write anything else you would like to share with P.S. 46
Your answer
Signature of parent/guardian completing this form.
*
Your answer
Date
*
MM
/
DD
/
YYYY
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