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Student Contact Update Form

Emergency Information

Fill in all information requested. We need at least 2 additional contact numbers. Please advise the front office of any changes as needed. Please note that no child will be released to any person(s) not indicated on the emergency contact sheet.

Please complete the form below. Required fields marked with an asterisk *

Student Contact Information

Student First Name:

Answer required for "Student First Name:"

Student Middle Name:

Answer required for "Student Middle Name:"

Student Last Name:

Answer required for "Student Last Name:"

Phone:

Number Required

Date of Birth:

Answer required for "Date of Birth:"

Grade:

Answer required for "Grade:"

Address

Street Address:

Answer required for "Street Address:"

City:

Answer required for "City:"

Zip/Postal:

Answer required for "Zip/Postal:"

Child Lives With:

Answer required for "Child Lives With:"

Both Parents

Both Patents Alternately

Mother Only

Father Only

Legal Guardian

Foster Parents

Other Adult

Special Custodial Court Instructions: (If yes, please provide a copy of the court order.)

Answer required for "Special Custodial Court Instructions: (If yes, please provide a copy of the court order.)"

Choose a file or drag it here.

Mother/Guardian

First Name:

Answer required for "First Name:"

Last Name:

Answer required for "Last Name:"

Email 1:

Answer required for "Email 1:"

Mobile Phone:

Number Required

Home Phone:

Number Required

Work Phone:

Number Required

Address

Street Address:

Answer required for "Street Address:"

City:

Answer required for "City:"

Zip/Postal:

Answer required for "Zip/Postal:"

Father/Guardian

First Name:

Answer required for "First Name:"

Last Name:

Answer required for "Last Name:"

Email 1:

Answer required for "Email 1:"

Mobile Phone:

Number Required

Home Phone:

Number Required

Work Phone:

Number Required

Alternate person to be contacted in case of emergency (must be over 18 and have picture ID to pick up child).

First Name:

Answer required for "First Name:"

Last Name:

Answer required for "Last Name:"

Relationship to Student:

Answer required for "Relationship to Student:"

Mobile Phone:

Number Required

Home Phone:

Number Required

Work Phone:

Number Required

Student Significant Health Problems:

Answer required for "Student Significant Health Problems:"

If emergency treatment is required, the school authorities will use their judgment to send the child to the most accessible hospital if none of the above-listed individuals can be reached.

Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"