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Emergency Form

Emergency Form 2023-2024 To Download and Print  (Please click)


SAMPLE

Child’s Name (Last) (First)_____________________________________________________________________
EMERGENCY HOME CONTACT CARD                                                                WISCONSIN SYNOD ELEMENTARY SCHOOLS
Dear parent or Legal Guardian: The wellbeing of your child is considered very important by our school. Frequently when children become seriously ill or injured we find it difficult to locate the parents, legal guardians or the family physician (in case you cannot be reached) for immediate actions. In order to make our health and safety programs more effective, we request your cooperation in filling out this report.
Child’s Name ____________________________________________
Date of Birth _____________________
Child’s Home Address _____________________________________
Home Phone No. _________________
Name of Father or Legal Guardian ____________________________________________________________
Place Where Father or Legal Guardian Works _____________________________________
Work Phone No. __________________ Cell Phone No. ___________________
Name of Mother __________________________________________________________________________
Place Where Mother Works __________________________________
Work Phone No. _________________ Cell Phone No. __________________
Family Physician __________________________________________ Telephone No. __________________
Family Email Address _____________________________
Family Cell Phone: _______________________ Whom shall we notify in case we are unable to reach either mother, father, legal guardian or family physician? ________________________________________________________________________________________
(Name) (Address) ________________________________________________________________________________________
(Home Phone) (Cell Phone)
RELATIONSHIP OF ABOVE NAMED PERSON TO CHILD ________________________________________
In case of serious accident or illness at school, the school principal will send your child to ___________________________ hospital, ___________________. If, in his opinion, emergency medical care is required, the legal responsibility for ambulance conveyance expenses and for medical expenses incurred on behalf of your child is a parental one. Please list any special requests you wish to make to help us aid your child in case of an emergency. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
Date _________________________
Signed ___________________________________________________ (Parent or Legal Guardian)
Please notify the school whenever any of the above information changes.