Emergency Forms

Fill in the form below to send me an email.

Child's Name: *

Birthdate: *

Address: *

City: *

Zip Code: *

Telephone #: *

Parent/Guardian Name: *

Work Phone: *

Cell Phone: *

Parent/Guardian Name:

Work Phone:

Cell Phone:

Person 1 Approved for Pick-Up: *

Relationship: *

Photo:

Work Phone: *

Home Phone: *

Cell Phone: *

Person 2 Approved for Pick-Up: *

Relationship: *

Photo:

Work Phone: *

Cell Phone: *

Home Phone: *

Person 3 Approved for Pick-Up:

Relationship:

Photo:

Work Phone:

Cell Phone:

Home Phone:

General Emergency Contact: *

Phone Number: *

Physician: *

Phone Number: *

Clinic: *

Phone Number: *

Dentist: *

Phone Number: *

Days Attending- Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Pick-Up Time (General): *

Any physical conditions/special needs that we should be aware of?

Allergies:

In case of an accident, serious illness, or ingesting of a hazadous substance, I give St. Raphael's Extended Day Program personnel my permission to contact the physician or emergency hospital listend avoe, call Poison Control, or administer syrup of ipecac, if I cannot be reached: *

Name:

Date:

St. Raphael's Catholic School

"Growing Together In Faith and Knowledge"