St Philip the Apostle
EMERGENCY INFORMATION
FAMILY NAME ______________________________________________________________
HOME PHONE ______________________________________________________________
HOME ADDRESS ______________________________________________________________
______________________________________________________________
CHILDREN ATTENDING SCHOOL (Oldest First) GRADE
_____________________________________________ ______
_____________________________________________ ______
_____________________________________________ ______
_____________________________________________ ______
_____________________________________________ ______
In case of EMERGENCY, ILLNESS or ACCIDENT
to the children named above, the SCHOOL is
authorized to proceed as indicated below:
(Number each item 1, 2, 3, 4 in order of the desired action.)
(
) Contact MOTHER at ______________________________________________________________________
place of
work
address
___________________________ _____________________________
__________________________
work number cell phone number pager number
(
) Contact FATHER at
_______________________________________________________________________
place
of work
address
___________________________
_____________________________ __________________________
work number cell phone number pager number
(
) Contact
____________________________________________________ ________________________
phone
(
) Take to emergency
hospital
_________________________________________________________________
(OVER)
Other important
information concerning the health of any of the children listed:
____________________________________________________________________________________________________
HOME SITUATION (Please circle the number of the
situation that applies)
1.
Living with both
parents
2.
Parents separated;
living with mother
3.
Parents separated;
living with father
4.
Father not living;
living with mother alone, or mother & stepfather (CIRCLE ONE)
5.
Mother not living;
living with father alone, or with father & stepmother (CIRCLE ONE)
6.
Parents divorced;
living with mother alone, or with mother and stepfather
7.
Parents divorced;
living with father alone, or with father and stepmother
8.
Living with
guardians who are relatives
9.
Living with single
mother/father (CIRCLE ONE)
10.
Other
_______________________________________________________________________________________
If #2 through #10 is circled; who has Custodial
Rights?
___________________________________________________
SHOULD YOU BE
SEPERATED OR DIVORCED:
Do you consent to the child(ren)’s non-custodial parent being apprised of his/her school behavior and/or academic standing should she/he so request?
Do you consent to the
child(ren) being released to the non-custodial parent?
COMMENTS: ______________________________________________________________________________________
DATE:
______________________ _________________________________________________________
Signature
of Parent or Guardian
PLEASE KEEP THIS
INFORMATION UP TO DATE. CALL THE SCHOOL
OFFICE IF THERE ARE ANY CHANGES.
THANK YOU!!