Fort Hamilton High School Emergency Contact Card
Please use this form to update your child's emergency contact information for Fort Hamilton High School. A representative from the school will contact you to verify the information.
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Student Information
Last Name: *
First Name: *
Middle Name:
Date of Birth: *
MM
/
DD
/
YYYY
Sex: *
Student's ID: *
Parent/Guardian Information:
Parent/Guardian (Student resides with): *
Relationship *
Parent/ Guardian's Preferred Language of communication: *
Written: *
Oral: *
Home Telephone: *
Work Telephone:
Cell No.: *
E-mail
Address: *
Apt.
City *
State: *
Zip: *
Other Parent/Guardian:
Relationship to student:
Second Parent/Guardian's Preferred Language of Communication:
Second Parent's Home Telephone:
Second Cell No.:
Second E-mail:
Second Address:
Second Apt:
Second City:
Second State:
Second Zip:
List 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 #1: *
Phone Number #1: *
Relationship #1: *
Name #2:
Phone Number #2:
Relationship #2:
Name #3:
Phone Number #3:
Relationship #3:
If there is a person who may NOT HAVE ACCESS to child. please indicate:
No Access Name:
Relationship to student:
Order of Protection Exists?
Clear selection
HEALTH INFORMATION
Name of Physician/Clinic: *
Telephone: *
Does your child have any health conditions that may affect participation in physical activities? *
Limitations (e.g. , stair climbing, participation in gym) :
Allergies:
504 services for the current year?   *
My child has: *
If "No Health Insurance," are you willing to share contact information from this card to learn about insurance options?
Clear selection
If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?                                                            It is understood that in the final disposition of an emergency case,  the judgement of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.                                                                
Does your child have any siblings?
List sibling's full name and school of attendance.
1. Sibling Name:
1. School of Attendance:
2. Sibling Name:
2. School of Attendance:
3. Sibling Name:
3. School of Attendance:
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