Emergency and Safety2012-2013 Academic Year

Contact Information This section needs to be filled out for each student each school year.

Student’s Name ____________________________________ Male Female

Grade (if in Preschool indicate program) __________________ Date of Birth _____________

Street Address _______________________________________________________________

City_____________________________ State__________________ Zip__________________ Primary Phone____________________ Primary Email ________________________________

Father’s Name ___________________________________ Home Phone___________________

Work Number____________________________ Cell Number__________________________

Company _________________________________ Position ____________________________

Hours at Work ________ to_________

Mother’s Name ___________________________________ Home Phone___________________

Work Number____________________________ Cell Number__________________________

Company _________________________________ Position ____________________________

Hours at Work ________ to_________

Forms can be dropped off in the office or mailed to: 2101 North Fremont St. + Chicago, IL 60614773.525.4990 + www.stjames-lutheran.org

Parents are always contacted first. Two emergency numbers other than the parent(s) must be on file.

Name _________________________________ Relationship __________________________

Phone _________________________________ Name _________________________________ Relationship __________________________

Phone _________________________________

Student Medical InformationThis section needs to be filled out for each student each school year.

Are there any medical conditions or food/animal allergies we should be aware of? Yes No

If yes, please explain.______________________________________________________________

_____________________________________________________________________________

Is your child on any kind of medication? Yes No

If yes, please explain. _____________________________________________________________

_____________________________________________________________________________

Physician’s Name ________________________________________________________________

Street Address __________________________________________________________________

City__________________________ State________________________ Zip_________________

Phone Number ________________________

Permission to Pick-Up a StudentThis section needs to be filled out for students entering preschool-fourth grade who will be picked up by someone other than their parents.

Name__________________________________ Relationship__________________________

Street Address _______________________________________________________________

City _______________________________ State ____________________ Zip____________

Phone _____________________________

Name__________________________________ Relationship__________________________

Street Address _______________________________________________________________

City _______________________________ State ____________________ Zip____________

Phone _____________________________

Name__________________________________ Relationship__________________________

Street Address _______________________________________________________________

City _______________________________ State ____________________ Zip____________

Phone _____________________________

When after school activities involve pick-up by individual(s) not listed above, written or verbal notification must be communicated to the office.