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SCHOOL EMERGENCY CONTACT & MEDICAL INFORMATION FORM
Student Name
Date of Birth
Month
Day
Year
Grade
Multi-line address
Country/Region
Address
City
Zip / Postal code
Parent/Guardian Information
Parent/Guardian #1
Name
Relationship to Student
Phone
Email
Employer
Work Phone
Parent/Guardian #2
Name
Relationship to Student
Phone
Email
Employer
Work Phone
Emergency Contacts (Other than Parents)
Contact #1
Name
Relationship
Phone
Authorized to Pick up Student?
Yes
No
Contact #2
Name
Relationship
Phone
Authorized to Pick up Student?
Yes
No
Medical Information
Primary Doctor
Doctors Phone
Health Insurance Provider
Policy Number
Known Allergies
Medical Conditions
Current Conditions
Emergency Medical Authorization
In the event I cannot be reached, I authorize the school and its representatives to obtain emergency medical treatment for my child if deemed necessary.
Parent/Guardian Signature
*
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Date
Month
Day
Year
Pick-Up Authorization
The following individuals are authorized to pick up my child from school:
Names
Parent/Guardian Signature
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Date
Month
Day
Year
Photo Release (Optional)
I give permission for my child's photo to be used in school publications, newsletters, social media, and promotional materials:
Permission:
Yes
No
Parent/Guardian Signature
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Date
Month
Day
Year
Submit
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