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Family Emergency Card
If emergency contact information is the same for each child, then only one form needs to be completed. If information is different for each child, then a new form would need to be completed for each child.
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* Indicates required question
Family Last Name
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Your answer
Student First Name(s) and Grade Level(s)
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Your answer
Family Address
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Your answer
Family City and Zip Code
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Your answer
Family Phone Number
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Your answer
Family Doctor
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Your answer
Family Doctor Phone Number
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Your answer
Hospital of Choice
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Your answer
Emergency Release (this SHOULD include parents/guardians as the first two contacts).
The following people have my permission to take my child(ren) from school in the event of an emergency or illness. In an emergency, the office will always call the emergency contacts in order until we have notified someone. (Please initial below)
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Your answer
1st Emergency Contact Name (Parent A/Guardian A)
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Your answer
1st Emergency Contact Relationship
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Your answer
1st Emergency Contact Primary Phone Number
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Your answer
2nd Emergency Contact Name (Parent B/Guardian B)
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Your answer
2nd Emergency Contact Relationship
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Your answer
2nd Emergency Contact Primary Phone Number
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Your answer
3rd Emergency Contact Name
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Your answer
3rd Emergency Contact Relationship
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Your answer
3rd Emergency Contact Primary Phone Number
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Your answer
4th Emergency Contact Name
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Your answer
4th Emergency Contact Relationship
*
Your answer
4th Emergency Contact Primary Phone Number
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Your answer
Non-Emergency Release:
The following people have permission to take my child(ren) from school in case of a non-emergency situation, such as early dismissal, medical appointments, car-pooling, or play dates, etc. (Please initial below).
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Your answer
Name 1
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Your answer
Relationship
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Your answer
Phone Number
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Your answer
Name 2
Your answer
Relationship
Your answer
Phone Number
Your answer
Name 3
Your answer
Relationship
Your answer
Phone Number
Your answer
Name 4
Your answer
Relationship
Your answer
Phone Number
Your answer
Permission to walk or ride bike home from school?
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Yes
No
Not Applicable
Authorization or Emergency Medical Treatment:
This information will be kept in the possession of the school/parish. A copy will be distributed to the person in charge of each trip or athletic activity in which the student participates. Should the need arise, this information will be given to the proper medical authorities. (
Please initial below
)
*
Your answer
I, as parent/guardian, understand that in the case of illness or injury to my child (
please list below
)
the school/parish will try to notify me or the person I have listed as an emergency contact. In the case of medical emergency concerning my child, at times when I or my listed emergency contact cannot be notified, I grant full power to the school/parish to 1) Arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including, but not limited to, an emergency room of a hospital, a doctor's office, or a medical clinic, and 2) Sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility.
(Please list child below, along with your name and relationship)
Your answer
Please sign below (typing your name acts as your signature) as authorization for all items listed on this form.
*
Your answer
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