• 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***