Emergency Medical Form
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1
22015-2016 School Year
Emergency Medical Authorization
School Building
*
Form/Student Information Form
Grade
C i t y S c h o o l s
Teacher/Homeroom
1. STUDENT INFORMATION
Name
Legal Last Name
Legal First Name
Legal Middle Name
Nickname
Address
Number & Street
Apartment
City
State
Zip Code
Home Phone
Unlisted?
Yes
No
Date of Birth
Gender:
Male
Female
Is child of Hispanic/Latino Heritage?
Racial Group:
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
White
(choose
all that apply – at least one)
Yes
No
Is child bused to or from a
A.M. only
P.M. only
Both
babysitter or child care provider?
Provider’s Name
Provider’s Address
Provider’s Phone
Child Care Provider Times
A.M. Bus #
P.M. Bus #
A.M. Shuttle #
P.M. Shuttle #
2. PARENT/GUARDIAN/FAMILY INFORMATION
If student is not living with both biological parents, a certified copy of court order or court-filed application is required. Has parents’ marital status changed since last school year?
Yes
No
Marital Status of Biological/Adoptive Parents
Married
Never Married
Legally Separated
Divorced
Separated (not filed)
Deceased
Legal Custody or Guardianship of Student
Both Parents
Mother Only
Father Only
Shared
Court-placed Guardian
*Student Living With
Birth/Adoptive Parents
Mother Only
Mother & Step
Father Only
Father & Step
Guardian
Foster Parent
Are custody papers, if applicable, on file with the school as required by Ohio law (ORC 3313.672) ?
Yes
No
Mother’s Full Name
Email Address
Primary Contact Number
Home
Work
Cell
Place of Employment
Secondary Contact Number
Home
Work
Cell
Work Number (
Yes
No
Available at work?
if different)
Primary # Unlisted?
Yes
No
Living with student?
Yes
No
Same as Student’s Address?
Yes
No
Emergency Contact?
Yes
No
Father’s Full Name
Email Address
Primary Contact Number
Home
Work
Cell
Place of Employment
Secondary Contact Number
Home
Work
Cell
Work Number (
)
Yes
No
Available at work?
if different
Primary # Unlisted?
Yes
No
Living with student?
Yes
No
Same as Student’s Address?
Yes
No
Emergency Contact?
Yes
No
Court-placed Guardian or Step-Parent’s Full Name
Email Address
Primary Contact Number
Home
Work
Cell
Place of Employment
Secondary Contact Number
Home
Work
Cell
Work Number (
Yes
No
Available at work?
if different)
Primary # Unlisted?
Yes
No
Living with student?
Yes
No
Same as Student’s Address?
Yes
No
Emergency Contact?
Yes
No
Parents or guardians listed above have permission to pick up the child unless otherwise indicated. Notify the school principal immediately if there are any court orders restricting noncustodial parents
or others from contact with the child. Provide the principal with a copy of the order. Do Not Release My Child To: _________________________________________________________________
Please Also Complete The Other Side of This Form
C:\Users\lgiermann\Desktop\Emergency Medical Form.docx\2/19/2016\Page 1 of 2
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