EMERGENCY CARD

PLEASE COMPLETE BLANK AREAS

PLEASE TURN FORM OVER – YOUR SIGNATURE IS REQUIRED______Student Name: Last First

Address: Is this a change of address from last school year? Yes No / City / Zip / Phone
School / Year
2014-2015 / Grade / Birth Date / Sex:  Male  Female
Parent/Guardian / Address (if different) / City/Zip / Relationship
Mother’s Name / Mother’s Occupation / Mother’s employer / Work # ( )
Cell # ( ) / Ext.
Father’s Name / Father’s Occupation / Father’s employer / Work # ( )
Cell # ( ) / Ext.
Physician/Practitioner______Phone ______
Medical Card #: ( )
Dr. Address: ______
Hospital: ______/ Special Health Considerations
  1. ______
  1. ______
  1. ______

IF YOU CANNOT BE REACHED, LIST TWO PERSONS WHO WILL BE AVAILABLE IN CASE OF EMERGENCY OR DISASTER

Name
1. / Relationship / Address/City / Phone
( )
2. / ( )

______

E-Mail Address Student Number

Dear Parent/Guardian:

The following information is desired for use in the event that your child becomes ill or is injured while at school or in case of an impending or actual disaster and you cannot be reached. In cases of minor nature, first aid will be administered. It is understood that the instructions given on this card will remain in force until revoked by the parent or guardian.

Indicate the action you want the school to take if the injury or illness is of a serious nature:

  1. Child should be placed in care of personal physician (as shown on reverse side).YesNo

Child should be placed in care of Christian Science practitioner (as shown on reverse side.)YesNo

  1. If physician/practitioner cannot be reached immediately, what action should be taken?
  1. In the event of injury to the mouth or teeth. List family dentist. Name:

Address: Phone:

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PHYSICAL EDUCATION REQUIREMENT

The State of California (E.C. 51222) states that every school child is required to take physical education unless legally exempt under E.C. 51241or E.C. 51246. When there is a legitimate reason for a student to be excused from physical education for one week or less, please send a note by the student to the health office. Any time an excuse will exceed one week, a form must be completed and signed by a physician.

Is there any reason why this student should not participate in the regular physical education program?YesNo

If “Yes”, please provide doctor’s excuse and state reason: .

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VERIFICATION OF RIGHTS

Governing boards of school districts are required to notify parents or guardians of their rights. Will you please sign and return the top portion of this card acknowledging that you have been notified of your rights as listed on the bottom portion of this card. Your signature does not indicate consent to participate in any particular program.

Signature of Parent/Guardian Date

REQUIRED DEMOGRAPHIC INFORMATION

1. Parent Education Level:

Please check the highest level of education obtained by any parent/guardian:

Check one only

 Not a high school graduate

 High school graduate or GEDSome college/Associate’s Degree

 College Graduate – Bachelor’s Degree

 Advanced college degree/graduate school – Master’s Degree or higher

2.Primary parent email address for all school correspondence: ______

3.Name of the parent(s)/guardian(s) with whom the student lives:

Name: / Relationship:
Name: / Relationship:

4.If shared custody, please list the name and contact information for the alternate parent/guardian:

Name: / Address:
Home No. / Cell No.

5.Other important registration information to complete:

  • Free & Reduced Lunch Form*: For your student to be eligible to receive free/reduced breakfast and lunch, you must fill out an application every year. Please fill out the enclosed application and return with your registration materials. *Students who are eligible for free/reduced lunch are also eligible to receive fee waivers for the following exams: ACT, SAT, PSAT and AP.
  • Health Form: If your student has any health issues (allergies, asthma, etc.) and/or takes any medication at school, please be sure to complete a Health History Form and return it with your registration packet. The Health History Form must be completed every year in order to keep your student’s health information up to date.

6.If you would like to add any additional emergency/alternative contacts for your student, please do so here:

Name: / Relationship
Phone No.: Alternate No.:
Name: / Relationship
Phone No.: Altnernate No.: