CTK School - Emergency Information Form

 

 

___________________________     ____________________________     __________________________

Last Name                                       Father                                               Mother

 

___________________________    ____________________________      ___________________________   

Student                                           Student                                             Student          

 

___________________________    ____________________________     ___________________________   

Student                                           Student                                             Student                                  

 

Home Address:___________________________________City:________________ Zip:_________Ph#___________

 

Mom’s Home                                                                  Dad’s Home

E-mail address:_____________________________            E-mail address:___________________________________

                                 *Please put an asterisk next to the phone number you would like us to call first.

Mother’s Place of Employment:                                                 Father’s Place of Employment:

 

___________________  Phone#_______________                      __________________  Phone#__________________

Business                      Pager#  ______________                       Business                   Pager# __________________

                                   Mobile# ______________                                                        Mobile#__________________

E-mail address_____________________________                      E-mail address_______________________________

                                        Mom’s at work                                                                                                     Dad’s at work

                                            *Please put an asterisk next to the e-mail address that you want the most info sent.

 

 List a neighbor or relative who will assume care of your child if you cannot be reached in an emergency:

 

_______________________________________________________________________________

                                                               Name/Relationship/Phone          

 

_______________________________________________________________________________

                                                               Name/Relationship/Phone 

              

Student lives with: [  ] Both Parents    [  ] Father Only    [  ] Mother Only     [  ] Father/Stepmother    [  ] Mother/Stepfather    [  ] Foster Parents

[  ] Legal Guardian    [  ] Other:_________________________

 

In case of serious illness, I request the school to contact me.  If the school is unable to reach me, I hereby authorize the school to call the physician listed below and follow his instructions.  If it is impossible to contact this physician, the school may make whatever arrangements seem necessary including transportation of the child.

 

Signature/Parent-Guardian______________________________

 

Allergies________________________________________       

 

Other Conditions___________________________________________

 

________________________________________________________

 

________________________________________________________

 

 

Physician_______________________________________

Address________________________________________

Physician's Office Phone___________________________

 

 

_____________________________________________     ____________________________________________

Student Name                                                               Student Name

 

_____________________________________________     _____________________________________________

Student Name                                                               Student Name

 

_____________________________________________     _____________________________________________

Student Name                                                               Student Name

 

 

[  ]  I will pick up my children every day before 3:00 p.m.       [  ]  My children are in a carpool w/_________________

                                                                                              and will be picked up every day before 3:00 p.m.

 

 

[  ]  _______________________________ will pick up my children on

     [  ] Mon     [  ] Tue     [  ] Wed     [  ] Thu     [  ] Fri

 

                 

[  ]  Has my permission to walk home                                 [  ]  Has my permission to ride a bicycle to and from school

      Comments:_______________________________               Comments:_______________________________

 

 

[  ]  My child(ren) ride the __________________________van/bus after school.                                                                        

       Van/Bus  -     Phone #___________________                      

       [  ] Mon     [  ] Tue     [  ] Wed     [  ] Thu     [  ] Fri

 

 

[  ]  My child(ren) are registered in CHRIST THE KING AFTER SCHOOL CARE:                                                                           

       [  ] Mon     [  ] Tue     [  ] Wed     [  ] Thu     [  ] Fri

 

 

[  ]  My child(ren) are not registered in CHRIST THE KING AFTER SCHOOL CARE, but if they haven't been picked up

       by 3:00 p.m., you have my permission to send them to CHRIST THE KING AFTER SCHOOL CARE and I will pay

       the current per-child drop-in rate.

                                               

 

ALL CHILDREN NOT PICKED UP BY 3:00 P.M. ARE SENT TO CHRIST THE KING AFTER SCHOOL CARE AND THE CURRENT DROP-IN RATE IS APPLIED.