List below names of three (3) persons who may be called in case of emergency or if child is sick in school.
CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD.
Name
Ryan Willowmack
Telephone
(
646
)
555-1212
Relationship
Nanny
Name
Craig Hofminer
Telephone
(
646
)
555-1212
Relationship
Neighbor
Name
Micah Zimmer
Telephone
(
646
)
555-1212
Relationship
Friend
If there is a person who may NOT HAVE ACCESS to child, please indicate:
Name
Charles Manson
Relationship
Stepfather
Order of Protection Exists?
Yes
X
No
Principal will be notified in writing of any changes to information on this card
Antonio Vargas
Signature of Parent/Guardian
IMPORTANT - PLEASE COMPLETE REVERSE SIDE OF THIS CARD > > > > > > > > > > > > > > > > > > > > >
Grade
Class
Room No.
Teacher
New York City Department of Education
HEALTH INFORMATION
Name of Physician/Clinic
Tribeca Pediatrics
Telephone
(
646
)
555-1212
Health Alert
Does child have any health condition that may affect participation in physical activities?
Yes
X
No
Limitations
None
(e.g., stair climbing, participation in gym)
Allergies
Peanuts, fish
504 services for the current year?
Yes
No
X
Previous year?
Yes
No
X
My child has (X any that apply):
Private health insurance
X
Medicaid
No health insurance
If "No Health Insurance," are you willing to share contact information from this card to learn about insurance options?
Yes
No
If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?
I authorize you to take any action they deem prudent and in the best interest of my child.
It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail.
The recommendation of the parent as indicated above will be respected as far as possible.
Siblings: Last Name
First Name
School of Attendance
Ramirez
Javier
PS 38 - The Pacific School
FOR SCHOOL USE.......................................................................................................................................................................
List below contacts made for emergency, illness or injury.