Emergency Contact form

Student information

Last name

First name

M.I.

Date of birth (mm/dd/yyyy)

Gender

OSIS ID #

Parent / Guardian

Last name

Parent / Guardian First name

Parent / Guardian Relationship

Preferred language — written

Preferred language — oral

Home telephone

Work telephone

Cell phone

Address

Apt #

City

Zip / Borough

Other parent / guardian

Last name

First name

Relationship

Preferred language — written

Preferred language — oral

Home telephone

Work telephone

Cell phone

Address

Apt #

City

Zip / Borough

Emergency contacts

Child will be released only to persons named on this card.

1 Emergency contact

Name

Telephone

Relationship

2 Emergency contact

Name

Telephone

Relationship

3 Emergency contact

Name

Telephone

Relationship

No access — person who may not have access to child

Name

Relationship

Order of protection?

YesNo

Siblings

Last name

First name

School

Last name

First name

School

Signature of parent / guardian

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 above will be respected as far as possible. Principal will be notified in writing of any changes to information on this card.

Signature

Date

Grade

Class

Room

Teacher

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Emergency Contact form

Address

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