SAMPLE
XYZ Charter
719
361/555-1234
Emergency Contact Information
This
form will be reproduced and placed in the file of each student listed
below. Please print legibly in ink.
Student 1:
Student's Name (Last, First, M.I.):
______________________________________________________________
Sex: ________________ Grade:____________ Age:_____________ Date of
Birth:_______________________
Student 2:
Student's Name (Last, First, M.I.):
______________________________________________________________
Sex: ________________ Grade:____________ Age:_____________ Date of
Birth:_______________________
Student 3:
Student's Name (Last, First, M.I.):
______________________________________________________________
Sex: ________________ Grade:_____________
Age:_____________ Date of Birth:______________________
Student 4:
Student's Name (Last, First, M.I.):
______________________________________________________________
Sex: ________________ Grade: ____________
Age:_____________ Date of Birth:_______________________
Primary Parent/Guardian Contact
Information:
Does child reside with this person? yes no
Name (Last, First):
__________________________________________________________________________________________
Relationship to
Student: ¨
mother ¨ father ¨
step-mother ¨ step-father ¨
other ___________________
Address:
__________________________________________________ Phone:
__________________________
Employer:
_________________________________________________________________________________
Please list contact phone numbers in
order of contact preference. Circle the appropriate type of number:
____________________________ (Cell/Work/Home/Pager) ___________________ (Cell/Work/Home/Pager)
____________________________ (Cell/Work/Home/Pager) ___________________ (Cell/Work/Home/Pager)
II. 6
Secondary Parent/Guardian Contact
Information:
Does child reside with this person? yes no
Name (Last, First):
__________________________________________________________________________
Relationship to
Student: ¨ mother ¨
father ¨ step-mother ¨
step-father ¨ other ________
Address:
__________________________________________________ Phone:
__________________________
Employer:
_________________________________________________________________________________
Please list contact phone numbers in
order of contact preference. Circle the appropriate type of number:
_______________________ (Cell/Work/Home/Pager) ___________________(Cell/Work/Home/Pager)
______________________ (Cell/Work/Home/Pager) ___________________
(Cell/Work/Home/Pager)
In the event of an
emergency and the school is unable to reach either parent or guardian indicated
on this form, please
list three (3) emergency contacts and phone numbers.
Name: (Last, First)
__________________________ Home Phone:_____________________________________
Work
Phone:_____________________________________
Cell
Phone:______________________________________
Name: (Last, First)
__________________________ Home Phone:_____________________________________
Work
Phone:_____________________________________
Cell
Phone:______________________________________
Name: (Last, First)
__________________________ Home Phone:_____________________________________
Work
Phone:_____________________________________
Cell
Phone:______________________________________