NOTIFICATION & EMERGENCY MEDICAL AUTHORIZATION

 PUPIL’S NAME: __________________________________         PHONE: ___________                                                      FIRST       MIDDLE                LAST

GRADE: ________                    BIRTH DATE:  ______________ 

ADDRESS:__________________________________________________________________                                               STREET                                  CITY                                 ZIP

MOTHER’S NAME: _____________________________________________ 

HOME ADDRESS: ______________________________________________ 

EMAIL ADDRESS: ______________________________________________ 

HOME PHONE: _________ BUS. PHONE: _________ CELL PHONE: ________ PAGER: ____________

 MOTHER’S PLACE OF EMPLOYMENT: __________________________________________________

 STEP-MOTHER’S NAME: (IF APPLICABLE) ___________________________________________

 STEP-MOTHER’S PLACE OF EMPLOYMENT: _________________________PHONE: _____________

FATHER’S NAME: _____________________________________________ 

HOME ADDRESS: ______________________________________________ 

EMAIL ADDRESS: ______________________________________________ 

HOME PHONE: ___________ BUS. PHONE: __________ CELL PHONE: _________ PAGER: _________ 

FATHER’S PLACE OF EMPLOYMENT: ___________________________________________________ 

STEP-FATHER’S NAME: (IF APPLICABLE) ______________________________________________

STEP-FATHER’S PLACE OF EMPLOYMENT: ______________________________PHONE: _________

IN A CASE OF ILLNESS OR EMERGENCY, THOSE OTHER THAN YOURSELF WHO MAY BE NOTIFIED:  (THIS AREA MUST BE FILLED OUT)

 

1.    NAME: ________________________________  ADDRESS: _____________________________ 

PHONE:  __________________ RELATIONSHIP: ____________________________ 

2.    NAME: ________________________________  ADDRESS: _____________________________ 

PHONE:  __________________RELATIONSHIP: ____________________________