Form Language
EMERGENCY INSTRUCTIONS
In the event a student is injured or for any other reason needs emergency attention, the following information is required.
ONLY ONE EMERGENCY FORM PER FAMILY MAY BE FILLED IN.
1. NAME OF STUDENT(S)
Name
Age
2. If an emergency, illness, or injury should occur at school or a school-related function, please give the names of persons to be contacted.
Name
Name
Mobile phone
Mobile phone
Work phone
Work phone
Relationship to student
Father
Mother
Grand Parent
Guardian
Relationship to student
Father
Mother
Grand Parent
Guardian
3. In case of a serious emergency and we cannot reach one of your contacts, please give the name of your physician or hospital you wish to be called as well as your preference as to an ambulance company.
Physician
Phone number
Hospital
Ambulance
4. In an emergency I authorize school authorities to take any steps necessary to administer medical treatment to my child(ren) in the event neither of the emergency contact persons can be reached:
Yes
No