Emergency Contact Click Here for a Print Friendly Version of the Emergency Contact Form Student InformationGradePre-K/DaycareKindergarten12345678TeacherReport RoomStudent's Name*Student's Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*List Other Children in this School DistrictNameSchoolGrade GuardiansFather's NamePlace of EmploymentPhoneMother's NamePlace of EmploymentPhonePerson to contact if parents are not available:Name*Phone*Relationship*Health InformationDo we have your permission to call an ambulance for your child, in case of injury?*YESNOPhysical and Dental exams are required by the State. Your child will be given private forms to be filled by your doctor or dentist.Name of Family DoctorIf these forms are not returned to us, we will schedule your child as follows: Physical Exams - Kindergarten or Grade 1, Grade 6, and Grade 11 Dental Exams - Kindergarten or Grade 1, Grade 3, and Grade 7 If your child is absent at the time of these exams, he/she will be scheduled the following year. ***Your signature below will give permission to do these exams.*** Please list any major health related issues we should be aware of. If your child has allergies or any physical problems, please indicate below.Health BackgroundDateReasonTreatment Parent/Guardian Signature*