* = Required Information
Student's Name
*
Address
*
Tel
*
Where parents can be reached if not at home?
Mother Name
*
Tel
*
Father Name
*
Tel
*
List two neighbors or nearby relatives who will assume temporary care of your child in case you can not be reached.
Name
Address
Tel
Name
Address
Tel
Date
In case of accident or serious illness, I request the school to contact me, if the school is unable to reach me, I authorize the school to call the physician indicated below and to follow his instructions, if it is impossible to contact this physician, the school may make whatever arrangements seem necessary.
Name of parents or guardians
*
Remarks
Allergies
May aspirin be given or tylenol
Yes
No
Other conditions
Physician's Name
Address
Office Tel
Other Tel
Security Code
*