Student Emergency Information

This information will be used in case of emergency dismissal from school.

Student 1 Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Student 2 Name
First Last
Birth Date
Date Format: MM slash DD slash YYYY
Student 3 Name
First Last
Birth Date
Date Format: MM slash DD slash YYYY
Student 4 Name
First Last
Birth Date
Date Format: MM slash DD slash YYYY
Parent/Guardian 1 Name*
First Last
P/G 1 Phone*
P/G 1 Work Phone*
P/G 1 Email*
Parent/Guardian 2 Name
First Last
P/G 2 Phone
P/G 2 Work Phone
P/G 2 Email
My/Our student/s may be released to:*
First Last
Phone*
My/Our student(s) may be released to:*
First Last
Phone*
My/Our student(s) may be released to:*
First Last
Phone*
Student Physician Name*
Physician Phone*
In case of emergency closure, please indicate how we are to release your student from school. Check all that apply.
- My student/s may walk home alone or with neighbors who attend St. Bernadette.
- My student may go home with the emergency contacts named above.
- My student/s must wait at school until I pick them up.
In the space below please list each student name with any medication and dosage they currently take.*
This is confidential information and will be used in case of emergency only.
In the space below, please list any health concerns, including allergies, for each student above.*
This is confidential information and will be used in case of emergency only.
Signature Parent/Guardian 1*
Signature Parent/Guardian 2

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