PLEASE PRINT

Student's Name Grade Birth Date

Parent's/Guardian's Name

Home Address Phone

Child Resides With mother father both guardian

Father's/Guardian's Employer Phone

Address Cell Phone

Mother's Employer Phone

Address Cell Phone

Alternate Person to be Notified Relationship

Address Phone

Second Alternate Relationship

Address Phone

Family Doctor Phone

List any allergies, special health problems or disabilities

In case of accident or serious illness, I request the school to contact me. If I cannot be reached, I hereby authorize the school to call the physician indicated above and follow his instructions. If it is impossible to contact this physician, the school may then attempt to admit my child to a convenient hospital or doctor's office.

The school staff has my permission to give Tylenol for minor aches when necessary Yes No

Parent or Guardian Signature Date