Family Emergency Form 2024-2025

Please complete the Family Emergency Form and submit by August 29, 2024. Children will not be admitted in September if the Emergency Form is not on file. One copy of the form will be kept in the school office and a copy will be on file in the Nurse's office. All information is kept confidential. ALL starred fields MUST be completed in order to submit your form.

1Family and Student(s) Information > 2Emergency Information > 3Review Your Entry
Family Name
Full Address
Has your home mailing address changed in the last 12 months?

Has your home mailing address changed in the last 12 months? Yes No
Mother's Email
Father's Email
Mother's Cell Mother's Cell - ### - ### ####
Father's Cell Father's Cell - ### - ### ####
Home Phone: Home Phone: - ### - ### ####
Primary Language Spoken at Home
Child 1 Name
COVID-19 Vaccination (1)
DOB (1) DOB (1) / MM / DD YYYY
Grade (1)
Child 2 Name
COVID-19 Vaccination (2)
DOB (2) DOB (2) / MM / DD YYYY
Grade (2)
Child 3 Name
COVID-19 Vaccination (3)
DOB (3) DOB (3) / MM / DD YYYY
Grade (3)
Child 4 Name
COVID-19 Vaccination (4)
DOB (4) DOB (4) / MM / DD YYYY
Grade (4)
Child 5 Name
COVID-19 Vaccination (5)
DOB (5) DOB (5) / MM / DD YYYY
Grade (5)
Parents/Guardian Name(s)
Mother's Employment
Hours
Work Phone Work Phone - ### - ### ####
Father's Employment
Hours
Work Phone Work Phone - ### - ### ####
Legal Guardian's Name (Full name of parent, grandparent, adoptive parent, stepparent or guardian)
Relationship to the Child(ren)

Relationship to the Child(ren) Mother Father Grandparent Adoptive Parent Stepparent Other Other
Case # if Guardianship is Court Decreed (Court Decrees MUST be on file in the school office)
Please indicate the BEST daytime phone number to use
Medical Issues

It is imperative that you inform us of your child’s medical needs. This information will be shared with appropriate personnel for your child’s safety. If medication is required during the school day, parents must bring the original container (both prescription & OTC) to school with written permission to administer. (See school website Parents' tab - Health and Wellness page for form) Prescription medications must have doctor’s instructions clearly labelled on the container & also doctor's signature on the permission form. NOTE: Students are not permitted to carry any medication to, or in, school. Please indicate your permissions below.
My child(ren) may receive:

My child(ren) may receive: Acetaminophen Ibuprofen (Grade 6-8 ONLY) Cough/Throat Drops
Exceptions or Special Circumstances:
My child(ren) wear(s):

My child(ren) wear(s): Glasses Contact Lenses
Known Bee Sting Reaction:

Known Bee Sting Reaction: Local Anaphylactic
Name(s) of Child(ren) who wear glasses
Name(s) of Child(ren) who wear contact lenses
Family Doctor
Doctor's Office Phone Doctor's Office Phone - ### - ### ####
Family Dentist
Dentist's Office Phone Dentist's Office Phone - ### - ### ####
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Family Emergency Form 2024-2025

Family Emergency Form 2024-2025

Medical Issues