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Emergency Information Form
Please fill out one form for each child registered at Saint Michael School.
*
Indicates required field
Student Name
*
First
Last
Parent/Guardian
*
First
Last
Home Phone Number
*
Cell Phone Number
*
Emergency Phone Number
*
Student Address
*
Line 1
Line 2
City
State
Zip Code
Country
Student Birthdate/Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
Gender
*
Male
Female
Grade
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Mother's Name
*
First
Last
Mother's Email
*
Mother's Cell Number
*
Mother's Work Number
*
Father's Name
*
First
Last
Father's Email
*
Father's Cell Number
*
Father's Work Number
*
Religion/Race/Ethnicity
Religion
*
Please make a selection
African Tradtional and Diasporic
Buddhism
Catholic
Chinese Traditional Religion
Christian
Greek Orthodox
Hinduism
Islam
Judaism
Other
Church / Parish
*
Baptized
*
Yes
No
Date of Baptism
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
Race/Ethnicity
*
Please make a selection
American Indian
Black
Asian
Hispanic
White
Native Hawaiian or Pacific Islander
2 or more races
Language
*
Please make a selection
English
Arabic
Armenian
Cape Verian
Chinese
Greek
Gujarti
Haitian Creole
Hebrew
Italian
Japanese
Khmer
Korean
Kreole
Lao
Polish
Portuguese
Russian
Spanish
Vietnamese
In Case of Emergency
Emergency Contact #1
*
First
Last
Relationship #1
*
Phone Number#1
*
Emergency Contact #2
*
First
Last
Relationship #2
*
Phone Number #2
*
Emergency Contact #3
*
First
Last
Relationship #3
*
Phone Number #3
*
Medical
Allergies
*
Insurance
*
Hospital
*
Is your child prescibed an EPI Pen
*
Yes
No
Health Issues
*
Insurance Policy Number
*
Doctor
*
Medications
*
Email Re: Medication or Health Issues
*
Doctor Phone Number
*
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 1
*
Yes
No
In case of emergency, does the school have permission to take your child to the nearest hospital?
Parental Consent 2
*
Yes
No
Dismissal
Please record how your child is transported from school in the afternoon:
Please check all that apply
*
Dropped off or pick up by parent/guardian
Walk (child has permission to walk home)
School Bus
Usually stays for Extended day
Parent/Guardian Signature
Name of Parent / Guardian who filled out online form:
Name
*
First
Last
By checking the box below, I am stating that all the information filled out on this form and is true and accurate:
True and Accurate
*
Checked box confirmation
Submit
Home
About
Faculty & Staff
Lunch Program
Athletics
Catholic Identity
>
Catholic Schools Week
Alumni
Mandatory Forms
Volunteers
Extended Day Program
Our Parish
Admissions
Visit
Apply
Re-Enroll
Tuition and Fees
From the Principal
Newsletter
Calendar
Support SMS
Auction
Playground Project