Limited Time Offer: Get 2 Months of ABCmouse.com for only $5!

Forms

Emergency Information Form

 

 

Student’s Name: ______________________   ______________________  __________

                              Last Name                              First Name                           Middle Initial

 

Student’s Address __________________________  ___________ _______  ___________

                               Street address/ Apt #                    City                 State        Zip Code

 

Student’s Age _______Date of Birth _________Student’s Phone Number___________

 

Grade _________ Teacher (Homeroom)/Classroom________________  Bus # ________

 

 

 

TO BE COMPLETE BY PARENT’GUARDIAN: TO SERVE YOUR CHILD I N CASE OF ACCIDENT OR SUDDEN ILLNESS, IT IS NECESSARY THAT YOU FURNISH THE FOLLOWING INFORMATION:

 

MOTHER’S NAME _____________________ _________________ _______________

                                    Last Name                               First Name              Middle Initial

 

Mother’s Employer ___________________________________ Phone #_____________

 

 

FATHER’S NAME ______________________ _______________ ________________

                                 Last Name                             First Name              Middle Initial

 

Father’s Employer____________________________________ Phone # _____________

 

 

GUARDIAN’S NAME ___________________ ________________ ________________

                                       Last Name                      First Name               Middle Initial

 

Guardian’s Employer __________________________________ Phone # ____________

 

In case of emergency, accident, or serious illness of the above named child, I request the school to contact me. If school personnel are unable to contact me, I hereby authorize them to call the following people who are authorized to pick up my child from school or a school-sponsored activity:

 

___________________________________ ____________________ ________________

                     Name                                          Phone Number                   Relationship

 

___________________________________ ____________________ ________________

                     Name                                          Phone Number                   Relationship

 

Doctor’s Name:______________________________________ Phone #:____________

 

Address: ______________________________________________________

 

If it is impossible to contact the physician named above, I hereby authorize the school to take action necessary to maintain the student’s health.

 

___________________________________________                       ___________________

                   Signature of Parent/Guardian                                                  Date

 

 

 

 

School-Related Student Trip Permission Slip and Medical Release Form

 

 

 

Student’s Name  _____________________ ________________________   __________

                                Last                                     First                                          Middle

 

School _______________________  Grade ________ Homeroom_________________

 

  All school-related trips for the ____________ school year; OR

 

 Field Trip Date(s) ________________   Destination _____________________

 

Alternate Destination, If applicable ______________________________________

 

Mode of Transportation_____________________ Cost to Student, if applicable $______

 

 

 

I hereby give permission for my child to participate in the above mentioned school-related student trip(s).

 

In addition, in the event of accident or sudden illness while on the school-related student trip, I authorize school personnel to contact the physician(s) listed on my child’s school enrollment data forms and authorize those physician(s) to render such treatment as may be deemed necessary in an emergence for the health of said child. In the event physician(s), parent(s), or other persons designated by the parent cannot be contacted, school personnel are hereby authorized to take whatever action is deemed necessary in their judgment for the health of said child.

 

 

___________________________________________________     __________________

          Parent/Guardian’s Signature                                                       Date

 

Please return this form to your child’s teacher.

Get 2 Months for $5!