Wednesday, November 22, 2017

Barnum Elementary School

EMERGENCY INFORMATION

 

STUDENT NUMBER:________________ GR:_____HOMEROOM:_______ TEACHER:______________

PLEASE COMPLETE THE FOLLOWING ***** PRINT CLEARLY *****_________________________

STUDENT INFORMATION:

LAST NAME:___________________________________ FIRST NAME__________________________________

Date of Birth: Male  Female  (Student Lives With): Parent  Guardian 

 HOME ADDRESS: ___________________________________________________________________________

HOME PHONE:______________________________ EMAIL: _________________________________________

Transportation:  Bus:  Walker  Other: (bus number) (please indicate)  Lighthouse (indicate an alternative to after school program)

PARENT/GUARDIAN INFORMATION:

MOTHER/GUARDIAN NAME:____________________________________________________________________

HOME ADDRESS______________________________________________________________________________

EMPLOYER'S NAME:___________________________________________________________________________

HOME PHONE:________________________________ WORK PHONE:_________________________________

BEEPER/PAGER:______________________________ CELLULAR/OTHER PHONE:________________________

FATHER/GUARDIAN NAME:_____________________________________________________________________

HOME ADDRESS:_____________________________________________________________________________

EMPLOYER'S NAME:___________________________________________________________________________

HOME PHONE:_________________________________ WORK PHONE:_________________________________

BEEPER/PAGER______________________________ CELLULAR/OTHER PHONE:_________________________

EMERGENCY CONTACTS: (SOMEONE OTHER THAN PARENT/GUARDIAN-LIST ANYONE WHO YOU GIVE PERMISSION TO PICK UP YOUR CHILD)

1) NAME _________________________________________________PHONE NUMBER:_______________________

2) NAME_________________________________________________ PHONE NUMBER:_______________________

3) NAME_________________________________________________ PHONE NUMBER:_______________________

4) NAME_______________________________ PHONE NUMBER:_____________________________

LIST ANY OTHER CHILDREN ATTENDING Barnum School:

NAME:_______________________________________ GRADE:____________ ROOM_________________

NAME:_______________________________________ GRADE:____________ ROOM_________________

NAME:_______________________________________ GRADE:____________ ROOM_________________

PARENT/GUARDIAN SIGNATURE: DATE:

*NOTIFY THE SCHOOL IMMEDIATELY OF ANY CHANGES IN THE ABOVE INFORMATION AT 275-2303***