Emergency Information
Page 1 of 3
1.
Child's Name
First Name / Last Name
First Name
M.
Last Name
2.
Date of Birth
mm/dd/yyyy
3.
Gender
Gender
Male
Female
4.
Grade
--None--
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
5.
Parent's/Guardian's Name
First Name / Last Name
First Name
M.
Last Name
6.
Daytime Phone
(XXX)-XXX-XXXX
7.
Evening Phone
(XXX)-XXX-XXXX
8.
Address
Address 1
Address 2
City
9.
State
--None--
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
10.
Zip Code
11.
Email Address
12.
Parent's/Guardian's Name
First Name / Last Name
First Name
M.
Last Name
13.
Daytime Phone
(XXX)-XXX-XXXX
14.
Evening Phone
(XXX)-XXX-XXXX
15.
Evening Phone
(XXX)-XXX-XXXX
16.
Address
Address 1
Address 2
City
17.
State
--None--
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
18.
Zip Code
19.
Email Address