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Petrides School 2020-2021 "Emergency Contact" Purple/Blue Card for Parents
Please complete the Emergency Home Contact, traditionally our blue and purple cards, below for your child. This form should be completed for each child currently enrolled in our school. Thank you for your cooperation!
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Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Grade Level for the 2020-2021 School Year (reminder for Parents/Guardians: please be sure to complete this survey for each individual child that you currently have enrolled in our school)
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PreK
K
1
2
3
4
5
6
7
8
9
10
11
12
Select one:
Male
Female
Clear selection
Student ID #
Your answer
Parent/Guardian that the Student resides with:
Your answer
Parent's Preferred Language of Communication
Your answer
Mother or Guardian's Name
Your answer
Mother or Guardian's Home Address
Your answer
Mother or Guardian's Home Phone Number
Your answer
Mother or Guardian's Work Phone Number
Your answer
Mother or Guardian's Cell Phone Number
Your answer
Mother or Guardian's Email Address
Your answer
Father or Guardian's Name
Your answer
Father or Guardian's Home Address
Your answer
Father or Guardian's Home Phone Number
Your answer
Father or Guardian's Work Phone Number
Your answer
Father or Guardian's Cell Phone Number
Your answer
Father or Guardian's Email Address
Your answer
Please list any Siblings including their Full Names, School of Attendance, and if they are under the age of 5.
Your answer
Please list any other approved emergency contacts including the individual's name, relationship to the child, and the home, work, and/or cell phone numbers. The child will be released ONLY to the persons named on this form.
Your answer
Medical Alert: My child has the following condition ________________. I will obtain the correct authorization forms from the school nurse for treatment
Your answer
Name of Physician/Clinic
Your answer
Does the child have any health condition that may affect participation in physical activities? If so, please list limitations (stair climbing, etc), allergies, and/or a 504 service for the previous and/or current school year?
Your answer
My child has...(check all that apply)
Private health insurance
Medicaid
No health insurance
If none of the contacts can be reached by phone, what do you wish the school to do in case the child is sick in school?
Your answer
Custodial Alert: I am requesting that my child NOT be released to __________________. I will provide the proper legal documentation to the school office to substantiate this request. Please state below this individual's relationship to the student and if an order of protection exists.
Your answer
It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent or guardian will be respected as far as possible.
Yes, I understand and agree.
No, I do not understand and agree.
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