EMERGENCY  CONTACT/MEDICAL  INFORMATION							STUDENT
										NAME
Student Name							Date of Birth
			(Please Print)
	Please Prioritize Emergency Contact Information:
First Contact:
	Relationship to Student:				Does the Student Live with you?      YES       NO
	Name:
	Address:
		City				State		Zip	Zip
Please circle the preferred number to reach you in case of an emergency during school hours.
	Home Phone:	(       )			Work Phone:	(       )
	FAX:	(       )			Cell:	(       )
	Pager:	(       )			EMail:
	Place of Employment:
	Name of Supervisor if Applicable:
…………………………………………………………………………………………………………………………………..
Second Contact:
	Relationship to Student:				Does the Student Live with you?      YES       NO
	Name:
	Address:
		City				State		Zip	Zip
Please circle the preferred number to reach you in case of an emergency during school hours.
	Home Phone:	(       )			Work Phone:	(       )
	FAX:	(       )			Cell:	(       )
	Pager:	(       )			EMail:
	Place of Employment:
	Name of Supervisor if Applicable:
…………………………………………………………………………………………………………………………………..
Third Contact:
	Relationship to Student:				Does the Student Live with you?      YES       NO
	Name:
	Address:
		City				State		Zip	Zip
Please circle the preferred number to reach you in case of an emergency during school hours.
	Home Phone:	(       )			Work Phone:	(       )
	FAX:	(       )			Cell:	(       )
	Pager:	(       )			EMail:
	Place of Employment:
	Name of Supervisor if Applicable:
Fourth Contact:
	Relationship to Student:				Does the Student Live with you?      YES       NO
	Name:
	Address:
		City				State		Zip	Zip
Please circle the preferred number to reach you in case of an emergency during school hours.
	Home Phone:	(       )			Work Phone:	(       )
	FAX:	(       )			Cell:	(       )
	Pager:	(       )			EMail:
	Place of Employment:
	Name of Supervisor if Applicable:
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Medical Information:
	Hospital Preference:
	Physician -	Name:
		Address:
		Phone:
	Known Allergies (include the severity of reactions and medications used to conteract or control allergy)
	Medications:
	Frequency of Dosage:
	Medical Conditions:
Signatures of Parents/Guardians:
	Signature / Relationship to Student						Date	Date
	Signature / Relationship to Student						Date	Date