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Emergency Contact

Student Information

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Home Phone

Answer Required

Mobile Phone

Answer Required

Email Address

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip Code / Postal Code*

Answer Required

Any health conditions we should know about in an emergency?

Answer Required

Mother / Guardian Information

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Email Address

Answer Required

Mobile Phone

Number Required

Work Phone

Number Required

Father / Guardian Information

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Email Address

Answer Required

Mobile Phone

Number Required

Work Phone

Number Required

Answer Required

Emergency Contact Information

List below names of three additional people who may be called in case of emergency or if child is sick in school. CHILD WILL BE RELEASED ONLY TO PEOPLE NAMED ON THIS CARD.

Name

Answer Required

Mobile Phone

Answer Required

Relationship to Student

Answer Required

Emergency Contact 2

Name

Number Required

Answer Required

Mobile Phone

Number Required

Relationship to Student

Answer Required

Emergency Contact 3

Name

Answer Required

Mobile Phone

Answer Required

Relationship to Student

Answer Required

Medical Information

Please click on the link below to download a hard copy of this form. This form will allow you to provide the school with medical information (e.g., allergies, medical insurance). Complete the form and give it to the Pupil Accountant Secretary.

https://www.schools.nyc.gov/docs/default-source/default-document-library/emergency-contact-card

Answer Required