STUDENT EMERGENCY AND HEALTH INFORMATION
This information is confidential, but may be shared with appropriate school personnel.  There are 3 mandatory sections.
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Email *
Student Legal Name *
Today's Date *
MM
/
DD
/
YYYY
Grade *
Student ID Number *
Address *
Home Phone Number *
Student lives with? *
Court documents restrict the following person(s) from picking up child from school. If there are no restrictions, please write "none".
If any name was listed on the previous question, legal documents must be on file on the CLMS office. Are Legal documents on file at CLMS? If the answer is no, a copy of these documents must be provided.
Clear selection
Father Name *
Father *
Father/Guardian Email Address *
Cell Number *
Place of Employment *
Work Phone Number *
Mother Name *
Mother/Guardian Email Address *
Mother *
Mother Cell Number *
Place of Employment *
Work Phone Number *
Cypress Lake Middle may disclose appropriately designated directory information only if you have given consent.  The primary purpose for the release of directory information is to allow CLMS to include your child's information in certain school publications.  Examples include: a playbill, showing your student's role in a drama production, the annual yearbook, honor roll or other recognition lists. *
MUST BE FILLED OUT: Person (s) who will care for student in case neither parent can be reached
MUST BE 18 YEARS OF AGE OR OLDER
(only people listed may pick up your child with proper identification)
Name *
Relationship *
Phone Numbers: Home/Cell/Work (list all) *
Name
Relationship
Phone Number: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
Name
Relationship
Phone Numbers: Home/Cell/Work (list all)
PARENT STATEMENT
I accept responsibility for notifying the school of any changes of home or business address or phone number. Students may receive State specified health services and vision, hearing, weight, BMI and scoliosis screening. Student may be exempted from any of these services if parent or guardian requests such exemption in writing. In the event of serious illness or accident and I cannot be immediately contacted, I give permission to have my child moved by ambulance or other conveyance to a doctor’s office or hospital for immediate attention. I also assume responsibility for payments of same. In case of an accident or illness where immediate treatment is not needed, but where my child is unable to remain in school, I request the school to contact me. If I am unable to be reached, I request that one of the persons listed above be contacted to care for my child until I can be reached. These persons have permission to transport my child. I understand that certain of my child’s educational records will be shared with District health care partners as needed to provide and evaluate health services and that certain of my child's medical treatment records created by health care personnel at school may be shared with school officials who have a legitimate need for access.
Please enter your name into the box below to show Parent Acknowledgement:  I understand that the information on this form will be the official student directory information.   *
Please type your name into the box to show Parent Acknowledgement: I agree that the above Student Emergency and Health Information may be executed by my electronic signature of this district form, which shall be considered as an original signature for all purposes and have the same force and effect as a manually signed original document and the document shall be binding on receipt of this form. *
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