BIRTHDAY________________

STUDENT EMERGENCY INFORMATION CARD

STUDENT NAME_________________________ PARENT/GUARDIAN__________________________________

HOME PHONE_____________
ADDRESS______________________________________

WORK PHONE______________
CELL PHONE__________________________

DOCTOR NAME/ADDRESS___________________________________________

PHONE____________________

HOSPITAL_______________________MEDICAL PROBLEMS/ALLERGIES______________________________
PICK-UP AUTHORIZATION: NAME & PHONE#
EMERGENCY CONTACT 1: NAME_______________________________________________________________
PHONE#_______________________________ADDRESS___________________________________________
EMERGENCY CONTACT 2: NAME_______________________________________________________________
PHONE#_______________________________ADDRESS___________________________________________

BIRTHDAY________________

STUDENT EMERGENCY INFORMATION CARD

STUDENT NAME_________________________ PARENT/GUARDIAN__________________________________

HOME PHONE_____________
ADDRESS______________________________________

WORK PHONE______________
CELL PHONE__________________________

DOCTOR NAME/ADDRESS___________________________________________

PHONE____________________

HOSPITAL_______________________MEDICAL PROBLEMS/ALLERGIES______________________________
PICK-UP AUTHORIZATION: NAME & PHONE#
EMERGENCY CONTACT 1: NAME_______________________________________________________________
PHONE#_______________________________ADDRESS___________________________________________
EMERGENCY CONTACT 2: NAME_______________________________________________________________
PHONE#_______________________________ADDRESS___________________________________________

I give permission to Manulele Elementary to make whatever emergency measures are judged
necessary for the care and protection of my child while under supervision of the school.
In case of an emergency, I understand that the local emergency unit to the hospital for treatment will
transport my child if the local emergency resource deems it necessary. The child will be transported
at the expense of the parents. It is understood that in some medical situations the staff will need to
contact the local emergency resource before the parent, childs physician and or other adult acting on
the parents behalf. I give the staff at North Como Preschool permission to contact my childs
physician if deemed necessary for emergency purposes.
Parent Signature________________________________________Date_______________________________
Child_______________________________________

I give permission to Manulele Elementary to make whatever emergency measures are judged
necessary for the care and protection of my child while under supervision of the school.
In case of an emergency, I understand that the local emergency unit to the hospital for treatment will
transport my child if the local emergency resource deems it necessary. The child will be transported
at the expense of the parents. It is understood that in some medical situations the staff will need to
contact the local emergency resource before the parent, childs physician and or other adult acting on
the parents behalf. I give the staff at North Como Preschool permission to contact my childs
physician if deemed necessary for emergency purposes.
Parent Signature________________________________________Date_______________________________
Child_______________________________________