Emergency Information Form

We will collect this data through an online form rather than a paper sent home. All information will be printed and stored in the office of Saint Michael School.

Student Demographics
STUDENT NAME
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PARENT / GUARDIAN
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Ex: Please write Mr. and Mrs. John and Sally in the "First Name" and add last name(s) to "Last Name" box.
STUDENT STREET
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HOUSEHOLD PHONE --
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BIRTH DATE //
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GENDER
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EMERGENCY PHONE -- ext
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MOTHER'S NAME
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MOTHER'S EMAIL
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WORK NUMBER --
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CELL NUMBER --
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EMPLOYER (M)
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FATHER'S NAME
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FATHER'S EMAIL
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WORK NUMBER --
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CELL NUMBER --
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EMPLOYER (D)
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HOMEROOM
HOMEROOM
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RELIGION / RACE / ETHNICITY
RELIGION
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CHURCH / PARISH
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BAPTIZED?
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DATE OF BAPTISM  
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RACE / ETHNICITY - NON HISPANIC
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RACE / ETHNICITY - HISPANIC
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LANGUAGE (FIRST)
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IN CASE OF EMERGENCY
NAME #1
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RELATIONSHIP
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NUMBER #1 --
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NAME #2
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RELATIONSHIP
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NUMBER #2 --
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MEDICAL
ALLERGIES
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HEALTH ISSUES
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List all current or active health conditions that apply to your child: ADD, ADHD, Lactose Intolerance, Migraines, etc...
MEDICATIONS
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Is your child prescribed an epi pen for treatment of allergy listed above?
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EMAIL TO CONTACT RE: MEDICATION OR HEALTH ISSUES
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INSURANCE
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POLICY NUMBER
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DOCTOR
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PHONE NUMBER OF DOCTOR --
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HOSPITAL
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PARENTAL CONSENT #1
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I hereby authorize you to contact my child's physician if i cannot be reached and such call is considered necessary. I also give permission to the school nurse to share information relevant to my child's health condition with appropriate school personnel as needed to meet my child's health and safety needs.
PARENTAL CONSENT #2
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In case of emergency, does the school have permission to take your child to the nearest hospital?
DISMISSAL
Please record how your child is transported from school in the afternoon:
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PARENT / GUARDIAN SIGNATURE
NAME OF PARENT / GUARDIAN WHO FILLED OUT ONLINE FORM
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Filling out the box below is your signature
CHECKED BOX / CONFIRMATION
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By checking the box below, I am stating that all the information filled out on this form and is true and accurate: