EMERGENCY INFORMATION

STUDENT’S SURNAME:

GIVEN NAME(S):

PREFERRED/CALLED NAME:

CLASS (YEAR):

DATE OF BIRTH:

LANGUAGE SPOKEN AT HOME:

HOME TELEPHONE NUMBER:

MOTHER/CAREGIVER SURNAME:

GIVEN NAME(S):

ADDRESS:

HOME TELEPHONE NO:

WORK TELEPHONE NO:

WORK PLACE/NAME OF FIRM:

CELLPHONE NO:

FATHER/CAREGIVER SURNAME:

GIVEN NAME(S):

ADDRESS (if different from above):

HOME TELEPHONE NO:

WORK TELEPHONE NO:

WORK PLACE/NAME OF FIRM:

CELLPHONE NO:

(Name of any other immediate caregiver you want on file, eg parent, stepmother/father)

CAREGIVER SURNAME:

GIVEN NAME(S):

ADDRESS (if different from above):

HOME TELEPHONE NO:

WORK TELEPHONE NO:

WORK PLACE/NAME OF FIRM:

CELLPHONE NO:

EMERGENCY SURNAME:

GIVEN NAME(S):

ADDRESS:

HOME TELEPHONE NO:

WORK TELEPHONE NO:

RELATIONSHIP (eg friend/grandparent):

CELLPHONE NO:

EMERGENCY SURNAME:

GIVEN NAME(S):

ADDRESS:

HOME TELEPHONE NO:

WORK TELEPHONE NO:

RELATIONSHIP (eg friend/grandparent):

CELLPHONE NO:

EMERGENCY SURNAME: GIVEN NAME(S):

ADDRESS:

HOME TELEPHONE NO:

WORK TELEPHONE NO: ___________________

RELATIONSHIP (eg friend/grandparent):

CELLPHONE NO:

DOCTOR:

MEDICAL CENTRE:

MEDICAL CONCERNS (see below for codes):

ANY OTHER CONCERNS YOU FEEL THE SCHOOL SHOULD BE AWARE OF:

L – Allergy

A - Asthmatic

J – Beesting

K – Bladder

I – Heart

D – Diabetes

E – Epilepsy

F – Fainting Spells

G – Glandular Fever

Y – Haemophilia

C – Headaces

M – Migraine

N – None

B – Nose Bleeds

R – Rheumatics

S – Sight

H – Hearing

O - Other