Parent/guardian Emergency Contact Form - Frankford Friends School

Parent/guardian Emergency Contact Form - Frankford Friends School - 2017-2018

Parent/Guardian Emergency Contact Form 2017-2018

Child’s Name: _______________________________________ Date of Birth: ______________ Grade: ________

___________________________________________________________________________________________

Health Insurance Carrier

Policy #

Exp. Date

(please write on line above)

Parent/Guardian 1:

Home Number: ____________________________Work Number:

Cell Number:______________________________ Email: _____________________________________

Parent/Guardian 2:

Home Number: ____________________________Work Number:

Cell Number:______________________________ Email: _____________________________________

Emergency Contact #1:_________________________________________________________________

(other than parent or guardian)

Relationship:______________________________ Phone Number:

Emergency Contact #2:_________________________________________________________________

(other than parent or guardian)

Relationship:______________________________ Phone Number:

Medical Conditions

Please list below any regular medications your child takes and any serious medical conditions that could

inhibit activity in regular school activities, including physical education classes.

__________________________________________________________________________________________________

Does your child have any allergies?

YES

Please list any allergies and your child’s reaction below:

Allergy

Reaction and Treatment

Please Note: Parents/Guardians are responsible for providing updated health and emergency contact

information to the school.

6/27/2017

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Parent/guardian Emergency Contact Form - Frankford Friends School - 2017-2018