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Emergency Student Blue Card 2021-2022
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
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Your answer
Student's Class and Teacher
*
Choose
3-K Song
Pre-K Porsha
K-011 Hoosein
K-012 Laderer
K-013 Vega
1-101 Taxin
1-102 Stambolski
1-103 Karfinkel
K/1-191 Sanford
2-201 Grassi
2-203 DeCaires
2-291 Pena
3-301 Rosner
3-302 Ellis-Lopez
3-303 Suh & Ehsan
3/4-491 Lucas
4-401 Somaiah
4-402 Bial
4-403 Kim
5-501 Schamberg
5-502 Humphries
5-503 Z.Moore & Campbell
4/5-591 Granville
Parent/Guardian that student resides with and Relationship
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Your answer
Cellphone Number
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Your answer
Parent's Preferred Language of Communication Written and Oral
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Your answer
Additional Contact Name & Number
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Your answer
Parent/Guardian Work Number
Your answer
Parent/Guardian Email Address
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Your answer
Home Address
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Your answer
Parent/Guardian Cellphone Number
Your answer
Parent 2 Work Phone Number
Your answer
Parent 2 Email Address
Your answer
CHILD WILL BE RELEASED ONLY TO THE FOLLOWING : Name,Telephone and Relationship
*
Your answer
CHILD WILL BE RELEASED ONLY TO THE FOLLOWING : Name,Telephone and Relationship
Your answer
CHILD WILL BE RELEASED ONLY TO THE FOLLOWING : Name,Telephone and Relationship
Your answer
Is there is a person who may NOT HAVE ACCESS to child?
*
Yes
No
Please list the person(s) who may NOT HAVE ACCESS to the child, based on legal order of protection. Type N/A, if not applicable.
*
Your answer
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