Student Emergency Information - St. Egbert Catholic School

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Student Emergency Information

Student's First and Last Name
Grade Level: *
PreK Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade
Mother's Name and Daytime Phone Number:
Father's Name and Daytime Phone Number:
We will need a list of neighbors, friends or relatives who will assume temporary care of your child if you cannot be reached. Please list in order to be contacted:
Person #1: Name, phone number, address and relationship: *
Person #2: Name, phone number, address and relationship:
Person #3: Name, phone number, address and relationship:
In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow his instructions. If it is not possible to contact this physician, the school may make whatever arragements seem neccessary.
Physician's Name and Phone Number:
Physician's Office Address and Emergency #:
Insurance Information:
Please list any allergies or known medical conditions: