EMERGENCY INFORMATION

 Student Name: __________________ Date of Birth: __________________ Grade: __________________

Social Security Number: _____________________   Bus Number: _________________

Parents’/Guardian Name(s): _____________________________________________________________

Address: ________________________________________   Telephone Phone: ____________________

City: ____________________ TN             Zip Code: ______________________________

Father’s work place & phone number: ______________________________________________________

Mother’s work place & phone number: _____________________________________________________

Please list below the names of persons who we need to contact in case your child becomes ill at school or an emergency occurs. Please start list with the first person you would want us to contact.

Name: ____________________________ Telephone Number: _____________________________

Name: ____________________________ Telephone Number: _____________________________

Name: ____________________________ Telephone Number: _____________________________

***LIST ANYONE WHO WOULD NOT HAVE LEGAL PERMISSION TO PICK UP YOUR CHILD FROM SCHOOL & PROVIDE DOCUMENTATION: _______________________________________

Please list names, grades, & ages of brothers or sisters: ________________________________________

INSURANCE COMPANY: _____________________________________________________________

            Policy Number: ________________________    Group Number: __________________________

Child Name__________________________   Sex: M__ or F__  Date of Birth_________   Age___

Father’s SS #_____________________________   Mother’s SS #________________________________

Father’s Work Address & Telephone #______________________________________________________

Mother’s Work Address & Telephone #_____________________________________________________

Another Person to Contact: _______________________________________________________________

            Relationship_________________________      Telephone Number:________________________

Allergies:____________________________________________________________________________

Consent Statement: AUTHORIZING TREATMENT

Parent’s Signature (REQUIRED)_________________________________________________________