Emergency Information Form

Child Information

Child's Name*

First Last

Child's Birth Date*

Cell Phone*

Child's Address*

Street Address City State ZIP Code

Name of School*

Grade*

Date to Start*

Teacher (if known)

Days / Times Attending*

Date Withdrawn

Parent Information

Parent / Guardian #1 Name*

First Last

Parent / Guardian #1 Work Telephone*

Parent / Guardian #1 Other Telephone

Parent / Guardian #1 Email Address*

Parent / Guardian #1 Work Address*

Street Address City State ZIP Code

Parent / Guardian #1 Home Address (if different from child)

Street Address City State ZIP Code

Parent / Guardian #2 Name

First Last

Parent / Guardian #2 Work Telephone

Parent / Guardian #2 Other Telephone

Parent / Guardian #2 Email Address

Parent / Guardian #2 Work Address

Street Address City State ZIP Code

Parent / Guardian #2 Home Address (if different from child)

Street Address City State ZIP Code

Additional Emergency Contact Information - Please list individuals (besides parents) with authorization to contact / pick up your child

Additional Emergency Contact #1 Name

First Last

Additional Emergency Contact #1 Relationship

Additional Emergency Contact #1 Telephone

Additional Emergency Contact #1 Address

Street Address City State ZIP Code

Additional Emergency Contact #2 Name

First Last

Additional Emergency Contact #2 Relationship

Additional Emergency Contact #2 Telephone

Additional Emergency Contact #2 Address

Street Address City State ZIP Code

Medical Information / Permission Statements

Child's Doctor's Name*

First Last

Child's Doctor's Telephone*

Child's Doctor's Address*

Street Address City State ZIP Code

Health Insurance Policy Number*

Health Insurance Policy Provider*

Please List all Allergies*

if none, please enter none

Please List any Special Needs*

if none, please enter none

Has your child been identified by the school district for special programming or have an IEP?*

Yes
No

Please provide details on special programming on IEP below:

Is there any medication, medical situation or dietary need that we should be aware of?*

Yes
No

Please describe these needs below:

Is there a custody agreement that would affect your child at BASE?*

if YES, we must have a copy

Yes
No

I give permission for my child to be transported to a hospital for treatment in an emergency.*

Yes
No

I give permission for my child to go on walks outside the school.*

Yes
No

I give permission for my child's picture to be used by BASE for advertising purposes.*

Yes
No

I give permission for my child to ride on school district buses if they need to be evacuated in an emergency.*

Yes
No

I understand that EWC will transfer my child's records at my request for 12 months after we leave.*

Yes
No

Parent's Signature (name)*

Permission*

I give permission for my child to receive medical treatment or first aid if needed.

Verification*

I certify that I have read, understand, and agree to comply with the provisions listed herein.