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Emergency Digital Form
A Parent/Guardian Must Complete this form. This form will last approximately 7 min. It is important that we have an emergency card for your child. If you have any questions or need assistance contact
Ms.Feliciano@jhs117.org
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* Indicates required question
The following information is based on the student attending Joseph. H. Wade 117X
Student First Name
*
Your answer
Student Last Name
*
Your answer
Grade for 2020-2021
*
6th Grade
7th Grade
8th Grade
OSIS Number (this is the 9 digit student id that the students use for lunch). If you do not know it, you can skip the question.
Your answer
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Address
*
Your answer
Apt #
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Student's Email Address
Your answer
Student's Cell Phone Number
Your answer
Student's Birthdate
*
MM
/
DD
/
YYYY
Siblings: Last Name, First Name, School of Attendance
Your answer
This section is for the Primary Guardian #1
Parent/Guardian #1 Name (First and Last)
*
Your answer
Parent/Guardian #1 Address
*
Your answer
Parent/Guardian #1 Apt #
*
Your answer
Parent/Guardian #1 City
*
Your answer
Parent/Guardian #1 State
*
Your answer
Parent/Guardian #1 Zip Code
*
Your answer
Relationship
*
Mother
Father
Grandparent
Sister/Brother
Aunt/Uncle
Other Realtive
Step Parent
Required
The best method to contact me is...
*
Cell Phone
Work Phone
E-mail
In-Person
WhatsApp
Text
Other
Other:
Required
Parent/Guardian #1 Email Address
Your answer
Parent/Guardian #1 Home Phone
Your answer
Parent/Guardian #1 Cell Phone
*
Your answer
Parent/Guardian #1 Work Phone
Your answer
Parent/Guardian #1 Spoken Language Preference
*
Your answer
Parent/Guardian #1 Written Language Preference
*
Your answer
This section is for the Primary Guardian #2
Parent/Guardian #2 Name (First and Last)
Your answer
Parent/Guardian #2 Address
Your answer
Parent/Guardian #2 Apt. #
Your answer
Parent/Guardian #2 City
Your answer
Parent/Guardian #2 State
Your answer
Parent/Guardian #2 Zip Code
Your answer
Relationship
Mother
Father
Grandparent
Sister/Brother
Aunt/Uncle
Other Relative
Step Parent
The best method to contact me is...
Cell Phone
Work Phone
E-mail
In-Person
WhatsApp
Text
Other
Other:
Parent/Guardian #2 Email Address
Your answer
Parent/Guardian #2 Home Phone
Your answer
Parent/Guardian #2 Cell Phone
Your answer
Parent/Guardian #2 Work Phone
Your answer
Parent/Guardian #2 Spoken Language Preference
Your answer
Parent/Guardian #2 Written Language Preference
Your answer
IN THE EVENT A STUDENT MUST LEAVE SCHOOL EARLY, THE STUDENT WILL ONLY BE RELEASED TO A PARENT/GUARDIAN OR A PERSON LISTED ON THE FORM BELOW.
EMERGENCY CONTACT #1 FIRST AND LAST NAME
*
Your answer
Emergency Contact #1 Phone Number
*
Your answer
Emergency Contact #1 Spoken Language
*
Your answer
Relationship to Student
*
Your answer
EMERGENCY CONTACT #2 FIRST AND LAST NAME
*
Your answer
Emergency Contact #2 Phone Number
*
Your answer
Emergency Contact #2 Spoken Language
*
Your answer
Relationship to Student
*
Your answer
EMERGENCY CONTACT #3 FIRST AND LAST NAME
*
Your answer
Emergency Contact #3 Phone Number
*
Your answer
Emergency Contact #3 Spoken Language
*
Your answer
Relationship to Student
*
Your answer
First Name and Last Name
Your answer
Relationship to Student
Your answer
Is there an Order of Protection
Yes
No
Clear selection
Name of Physician and Clinic:
*
Your answer
Telephone for Physician/Clinic
*
Your answer
Does child have any health condition that may affect participation in physical activities?
*
Yes
No
Limitations (examples: climbing stairs, participating in gym)
*
Your answer
Does the student have any allergies (Please specify)
*
Your answer
Is there any health information you would like us to be aware of?
*
Your answer
Does the student have any 504 services?
*
No
Yes (currently for 2020-2021)
Yes ( Last Year 2019-2020)
My child has:
*
Private Health Insurance
Medicaid
No Health Insurance
If “No Health Insurance,” are you willing to share contact information from this card to learn about insurance options?
*
Yes
No
If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured? It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail.The recommendation of the parent as indicated will be respected as far as possible.
*
Your answer
Please identify the student's current living arrangements. Please check one (1).
*
Permanent Housing (student who is living in a fixed, regular and adequate housing situation)
Doubled Up ( with another family or other person because of loss or as a result of economic hardship)
Shelter( Emergency or transition shelter)
Awaiting Foster Care Placement
Hotel/Motel (Living in what is NOT an emergency or transitional shelter and involves payment)
Other Temporary Living Situation (Trailer park, campground, car, public places, abandoned building, street or any other inadequate living space)
Required
Do you provide CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE(e.g. educational, public service, or health awareness purposes).
*
Yes
No
The Parent Association of JHS117 requests the contact information of each family to provide information and support services. If you do or do not permit the school to share your name, telephone number, and email information, please check the button below.
*
Yes
No
Head to our website for school information and to sign up for REMIND our school text message service.
By typing in my name below, I affirm that I am the parent/legal guardian of the student whose information has been submitted via this electronic form.
*
Your answer
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