Student Emergency Information 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 PhoneP/G 2 Work PhoneP/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