Emergency Form

Student Information

Child's Name*

First Last

Days*

Class*

Birth Date*

MM

DD

YYYY

Gender*

First Parent Name*

First Parent Cell Phone*

First Parent Email*

Second Parent Name

Second Parent Cell Phone

Second Parent Email

Home Phone*

First Contact Name*

Relationship*

First Contact Phone*

Second Contact Name*

Relationship*

Second Contact Phone*

Third Contact Name*

Relationship*

Third Contact Phone*

Current Medications*

Allergies*

Other Health Issues*

Please check the following.*

In case of illness, accident or emergency, we consent to medical emergency care to our child (children) that may be deemed necessary by any physician, hospital, or St. James' Parish Day School employee without obtaining further consent.
In case of illness, accident or emergency, we DO NOT consent to medical emergency care to our child (children) that may be deemed necessary by any physician, hospital, or St. James' Parish Day School employee without obtaining further consent.

Please check the following.*

My child (children) has permission to participate in field trips during the school year
My child (children) DOES NOT have permission to participate in field trips during the school year