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Emergency Contact & Health Form
Section 1: Student Information
Student's Full Name
Date of Birth
*
Grade Level (Fall 2025)
*
Home Address
*
Parent/Guardian Name(s)
*
Phone Number(s)
*
Email Address(es)
*
Section 2: Emergency Contacts (other than parent/guardian)
Name:
*
Relationship to student
*
Phone Number
*
Name:
*
Relationship to student
*
Phone Number
*
Section 3: Medical Information
Physician's Name & Phone Number
*
Preferred Hospital
*
Medical Insurance Provider (optional)
*
Physical limitations or activity restrictions
*
Allergies (food, medication, environmental)
*
Current Medications
*
Section 4: Consent
Signature Block
Full Name (typed)
Date:
*
Signature
Submit
