Emergency Contact Form - Collaborative School of the Arts

Student's Name*
First Last
Program(s) Child is Attending:*
Date of Birth:*
MM slash DD slash YYYY
Age of Student:*
Grade:*
Gender:*
Personal Pronoun:
- Him/He/His
- She/Her/Hers
- They/Them/Their
Parent/Guardian(s) Name*
First Last
Parent/Guardian(s) Relation to Student:*
Contact Me Here:
Email:*
Home Phone, if applicable
Cell Phone*
Work Phone
If You Can't Reach Me, Please Call:
Name:
First Last
Relationship to Student:
Home Phone, if applicable
Cell Phone:
Work Phone:
Medical Information
Allergies:
Life Threatening
- Yes
- No
Current Medications:
Other Notes/Special Needs:
Electronic Signature In the event of a medical emergency, I give permission for my child to be taken to the nearest medical care facility, should treatment be needed. By typing your name below and hitting Submit, you are agreeing to the above.
Signature*
First Last
Date*
MM slash DD slash YYYY

Contact Me Here: