Emergency Contact Update

Please complete the form below. Required fields marked with an asterisk *

Front:

emergency contact

Student Information

Student Name*

Answer Required

Student Date of Birth*

Answer Required

Student Sex

Answer Required

Male

Female

Student ID Number

Answer Required

Parent/Guardian (student resides with) Information

Parent/Guardian (student resides with) Name:

Answer Required

Relationship to Student:

Answer Required

Parent/Guardian's Preferred Language of Communication

Answer Required

English

Spanish

Arabic

Bangla or Bengali

Fulani

Urdu

Vietnamese

Wolof

Other:

Parent/Guardian's Home Phone Number

Answer Required

Parent/Guardian's Cell Phone Number

Answer Required

Parent/Guardian's Work Phone Number

Answer Required

Parent/Guardian's Email Address

Answer Required

Parent/Guardian's Mailing Address

Answer Required

Other Parent/Guardian Information

Other Parent/Guardian Name

Answer Required

Other Parent/Guardian Relationship

Answer Required

Other Parent/Guardian's Preferred Language of Communication

Answer Required

English

Spanish

Arabic

Bangla or Bengali

Fulani

Urdu

Vietnamese

Wolof

Other:

Other Parent/Guardian's Home Phone Number

Answer Required

Other Parent/Guardian's Cell Phone Number

Answer Required

Other Parent/Guardian's Work Number

Answer Required

Other Parent/Guardian's Email Address

Answer Required

Other Parent/Guardian's Address

Answer Required

Release of Child

** CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS FORM

Name, Phone Number and Relationship of a person who may be called in case of emergency or if a child is sick in school.

Answer Required

Name, Phone Number and Relationship of a person who may be called in case of emergency or if a child is sick in school.

Answer Required

Name, Phone Number and Relationship of a person who may be called in case of emergency or if a child is sick in school.

Answer Required

If none of the named contacts above can be reached, what do you wish the school to do if your child is sick or injured?

Answer Required

** It is understood that in the final disposition of an emergency case, the judment of the school authorities will prevail.

**The recommendation of the parent as indicated above will be respected as far as possible.

If there is a person who may NOT HAVE ACCESS to child, please indicate Name, Relationship and if an order of protection exists.

Answer Required

BACK:

Back of Emergency Contact Card

Health Information

Name of child's Physician/Clinic and contact information:

Answer Required

Does child have any health condition that affect participation in physical activites?

Answer Required

Yes

Physical Limitations:

Answer Required

Does child have any allergies?

Answer Required

Yes

Allergies:

Answer Required

Does child have 504 plan for this year?

Answer Required

Yes

Did child have 504 plan last year?

Answer Required

Option

Siblings

Please list the names of any siblings and their schools of attendance.

Answer Required

Confirmation

Acknowledgement of notification*

Answer Required

Principal will be notified in writing of any changes to information on this form.

Name of person completing this form*

Answer Required

Fannie Lou Hamer Freedom School

Please fix the highlighted areas below before submitting.

Emergency Contact Update