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     Click Here to Download this Form- Emergency Information Form for Students
    Rochester City School District - Emergency Information Form

    It is extremely important that we keep our files up to date with the correct emergency information for all students.  Please fill out this form and return to school immediately.  All information will be kept strictly confidential to be used only by the principal, teacher, secretary, or nurse.

     

    Please complete and return to the school office tomorrow.

     

    Name of Student ____________________________________________________DOB ________________________

                                                    (Last)                                       (First)

     

    Home Address __________________________________________________________________________________

     

    School ________Grade _____ Teacher_________________________ Home Phone__________________________

     

    Parent/Guardian(s) _________________________ Located at_______________________  ____________________

                                                                                                                    (During School Hours)           (Phone Numbers)

                                    __________________________ Located at _______________________  ___________________

                                                                                                                    (During School Hours)           (Phone Numbers)

    If student resides with someone other than Parent/Guardian, write name and telephone number:

     

     

    Other children in this school (first and last names): _______________________  ___________________________

     

                                                                                            _______________________  ___________________________

     

    Note:  Please advise these individuals that you are listing them for emergency care in case the school is unable to reach you.

    __________________________________________________at _______________________    __________________

                    (Name-indicated if relative, neighbor, friend)                          (Phone Numbers)                    (Phone Numbers)

     

    __________________________________________________at _______________________    __________________

                    (Name-indicated if relative, neighbor, friend)                          (Phone Numbers)                    (Phone Numbers)

     

    In the event of emergency, illness, or injury, the persons listed below will be contacted for care and transportation: 

     

    1.        Student’s Physician _________________________________________ at ______________________________

    (Name)                                                    (Phone Number)

     

    2.        Student’s Dentist ___________________________________________ at ______________________________

    (Name)                                                    (Phone Number)

     

    3.        Hospital/Clinic Preference (when possible) __________________________ at ___________________________

    (Phone Number)

     

    4.        Student’s Medical Insurance Carrier ______________________________________________________________

    In the event the student has a medical emergency and the parent/guardian or designated persons cannot be immediately contacted, school authorities will carry out their responsibility to ensure that the student receives medical assistance.

    ________________________________________                _______________________________________________

    Date                                                                                         Parent/Guardian Signature