Family Information Card

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Family Information Card

This form provides all the necessary information to contact parents or guardians.

  • Only complete this form if the Student Contact/Health Information has changed. If your information HAS NOT changed, please fill out the Student Contact/Health Information form in your registration packet, check the box "No Changes" , sign and return to the front office.
  • This is the primary email address to be used for communication.
  • List all.
  • Father's address if different from student's address.
  • If different from above.
  • Mother's address if different from student's.
  • If different from above.
  • Date of Birth
    MM slash DD slash YYYY
  • Please list all allergies or health issues.
  • Please list all medications, dosage and frequency as required.
  • Date of Birth
    MM slash DD slash YYYY
  • Please list all allergies or health issues.
  • Please list all medications, dosage and frequency as required.
  • Date of Birth
    MM slash DD slash YYYY
  • Please list all allergies or health issues.
  • Please list all medications, dosage and frequency as required.
  • Date of Birth
    MM slash DD slash YYYY
  • Please list all allergies or health issues.
  • Please list all medications, dosage and frequency as required.
  • Parents: Please list someone other than yourself or your spouse as an Emergency Contact.
  • Parents: Please list someone other than yourself or your spouse as an Emergency Contact.
  • Will your child/children be transported by...? Choose all that apply.
  • If your child will be using different options of transportation please provide additional details.
  • If you or your emergency contact(s), as indicated above, cannot be reached in an emergency and, if in the judgement of the school authorities immediate medical and / or hospital attention is indicated, do you authorize the school authorities to send your child (appropriately accompanied) to an available hospital?
  • As a parent and/or legal guardian, I authorize the treatment of my minor child/children by a qualified and licensed medical doctor or Emergency Medical Technician (EMT) in the event of an emergency which, in the opinion of the attending physician or Emergency Medical Technician (EMT), may endanger his or her life, cause physical disability or undue discomfort if delayed. This consent is granted only after a reasonable effort has been made to reach me. By filling out the signature box and the printed name box below in lieu of a physical signature, this will provide the same permission.
  • Verification
  • Verification
  • Clear Signature

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