Emergency Information

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-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th 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--ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

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--ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

18.	Zip Code

19.	Email Address