Emergency Contact

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• Student Information

• Grade
  Pre-K/DaycareKindergarten12345678
• Teacher
• Report Room
• Student's Name*
• Student's Birth Date*
  Month123456789101112

  Day12345678910111213141516171819202122232425262728293031

  Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
• Address*
  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 District

  Name	School	Grade

• Guardians

• Father's Name
• Place of Employment
• Phone
• Mother's Name
• Place of Employment
• Phone
• Person to contact if parents are not available:
• Name*
• Phone*
• Relationship*

• Health Information

• Do we have your permission to call an ambulance for your child, in case of injury?*
  • YES
  • NO
• Physical 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 Doctor
• If 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 Background

  Date	Reason	Treatment

• Parent/Guardian Signature*