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2023/2024 Weekend Emergency Card
Please fill this form as it is a portable record of your child's information in case of an emergency
* Indicates required question
Child's First & Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Primary Guardian Email Address
*
Your answer
Alberta Health Card #
*
Your answer
Doctor Name and Contact Number
*
Your answer
Immunization up to date
*
Yes
No
Do not Immunize
Required
Any Medical Issue
*
Yes
No
If the child has any medical history, please explain
*
Your answer
Allergies
*
Yes
No
Unaware of
If the child has an allergy please explain in details
*
Your answer
Does the child require an EpiPen or inhaler. if your answer is yes, please provide one for the Weekend School with full name of the child and prescription form filled out and signed
*
Yes
No
Does your child have any Behavior or Academic Challenges that may require one on one assistance
*
Your answer
Child's Address
*
Your answer
Postal Code
*
Your answer
Mother's First & Last Name
*
Your answer
Mother's Contact Number (Cell)
*
Your answer
Mother's Email
*
Your answer
Father's First and Last Name
*
Your answer
Father's Contact Number (Cell)
*
Your answer
Father's Email (Must be different than Mother's)
*
Your answer
First Emergency Name (Full) OTHER THAN PARENTS
*
Your answer
First Emergency Contact Number (Cell)
*
Your answer
Second Emergency Name (Full) OTHER THAN PARENTS
*
Your answer
Second Emergency Contact (Cell)
*
Your answer
Parent's Initials
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
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