Family Emergency Form
Please fill out a separate form for each student attending Cornerstone
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Student First Name
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Student Last Name
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Student Allergies
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Does your student use an EpiPen or inhaler? It is your responsibility to alert the study hall monitor and tutors where to find this in an emergency.
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Please list any medical conditions we should be aware of that might affect your student while at Cornerstone. PLEASE NOTE: this form goes to our study hall monitor for emergencies. If something might happen during class or an issue your student is dealing with (seizures, frequent restroom breaks, etc.) you must inform the tutor as well.
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Mother/Guardian First Name
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Mother/Guardian Last Name
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Mother/Guardian Phone Number (Best number during school hours) *
Father/Guardian First Name
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Father/Guardian Last Name
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Father/Guardian  Phone Number (Best number during school hours)
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Parent/Guardian full address
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Emergency Contact (other than those listed above)
Please list Name, relation, phone number
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Insurance Company
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Policy Number / Group #
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Physician Name and Number
 *
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