Please fill out the attached emergency information sheet. Please print clearly.

SAINTS PETER AND PAUL BEFORE AND AFTER SCHOOL

Emergency Form 2008-2009

Please Print clearly

Grade____

Student Name________________________________________________ DOB____________________

Address_____________________________________________________ City___________________ Zip____

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Parent/Guardian Information – Please print clearly

Mother Father

Name___________________________________ Name____________________________

Address________________________________ Address___________________________

Home Ph #______________________________ Home Ph#_________________________ Employer_______________________________ Employer__________________________

Address_________________________________ Address___________________________

City____________________St.____ Zip_______ City_________________ St. ___Zip_____

Work# w/area code_______________________ Work# w/area code___________________

Cell Ph#_____________________________ CellPh#____________________________

Child lives With ___Both Parents ___Mother ___Father ___Other

If there is someone other than the parent/guardian who may be picking up your child/children, please put their names

& relationship to the child/children here:

__________________________________________________________________________

If there are persons who may not pick up your child/children, please put their name & relationship to the child here:

________________________________________________________________________________________

Does your child have any food or other allergies & does he/she take medications for these allergies?

_________________________________________________________________________

3 MANDATORY EMERGENCY CONTACTS (other than parents)

1.Name_______________________________ ___ Relationship____________

Address_________________________ City__________ St. ___ Zip_____

Home#_______________Work #________________ Cell Ph#_______________

2.Name___________________________________ Relationship______________

Address__________________________ City_______________ St. ___ Zip____

Home #___________________Work #______________Cell Ph#_______________

3. Name __________________________________ Relationship_______________

Address_________________________ City________________ St. ___ Zip_____

Home #________________Work #_______________Cell Ph#_______________

ALL STUDENTS MUST HAVE 3 EMERGENCY CONTACTS OTHER THAN PARENTS