Emergency Information Form
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2CHESTER COUNTY SCHOOL SYSTEM
Emergency Information
Must be completed by parent or guardian
School ______________________________________________________________________________
Name of Student __________________________________________ Date of Birth _________________
Grade ____________Teacher/Homeroom Teacher ______________________ Bus # ________________
Student’s Address _____________________________________________________________________
City _________________________________________ State ____________ Zip Code ______________
o
o
Sex
M
F
Race ___________________________________________________________
Mother/Guardian’s Name ____________________________________ Home Phone _________________
Mother/Guardian’s Address __________________________________ Cell Phone ___________________
City _________________________________________ State ____________ Zip Code ______________
Mother/Guardian’s Workplace ________________________________ Work Phone _________________
Father/Guardian’s Name ____________________________________ Home Phone _________________
Father/Guardian’s Address ___________________________________ Cell Phone ___________________
City _________________________________________ State ____________ Zip Code ______________
Father/Guardian’s Workplace _________________________________ Work Phone _________________
o
o
o
o
Child lives with
Mother
Father
Both
Other (Specify) ___________________
o
o
o
o
If divorced, who has custody?
Mother
Father
Joint
Other (Specify) _________
CUSTODY ISSUES BETWEEN PARENTS MUST BE VERIFIED WITH LEGAL DOCUMENTATION IN THE SCHOOL OFFICE.
Please list names, grades and ages of any brothers and/or sisters: _______________________________
____________________________________________________________________________________
Contact list: If your child becomes sick, injured, or has an immediate need at school, please list persons
that you wish for us to contact. Please list them in order that you wish for them to be called. Please note
if the number is a cell number (c), home phone (h), work phone (w), or list extension numbers.
1. Name ________________________________________________ Phone ______________________
2. Name ________________________________________________ Phone ______________________
3. Name ________________________________________________ Phone ______________________
4. Name ________________________________________________ Phone ______________________
COMPLETE SIDE 2.
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Parent category: Business