HAMILTON SOUTHEASTERN SCHOOLS STUDENT EMERGENCY CONTACT INFORMATION FORM
**RETURN FORM TO THE SCHOOL OF THE STUDENT NAMED BELOW**
STUDENT INFORMATION (COMPLETE ONE FORM FOR EACH STUDENT – PLEASE PRINT NEATLY) Student Name ___________________________________
LAST
_______________________________
FIRST
___________________
MIDDLE
Grade _______ School ________________________________ Birth Date _____________ Gender _____ ID# __________ Primary Guardian ___________________________________ Relationship to Student ___________________________ PRIMARY OR SECONDARY GUARDIAN (CHANGES ONLY) - PLEASE PRINT NEATLY Guardian Name ___________________________________
LAST FIRST
________________________________
__________________
MIDDLE
Address ___________________________________________________ City/State ___________________ Zip _________ 1st Phone (_______) ___________________ 3rd Phone (_______) ___________________ Home Cellular Work Other Home Cellular Work Other Primary
(Circle One) (Circle One) (Circle One)
Unlisted?
Yes
No
2nd Phone (_______) ___________________ Home Cellular Work Other
Relationship to Student _____________________________________
Secondary
(Circle One)
MEDICAL EMERGENCY INFORMATION (REQUIRED) - PLEASE PRINT NEATLY Doctor ___________________________________________________________________ Phone (______) ________________
LAST FIRST M.I.
Dentist __________________________________________________________________ Phone (______) ________________
LAST FIRST M.I.
Hospital Preference _____________________________________________________________________________________ EMERGENCY CONTACTS (REQUIRED) - PLEASE PRINT NEATLY
Please list any contacts we may call if we are unable to reach the primary or secondary guardian.
1.) Name _____________________________________
LAST
_________________________________
FIRST (Circle One) (Circle One) (Circle One)
____________________
MIDDLE
1st Phone (_______) ___________________ 3rd Phone (_______) ___________________
Home Cellular Work Other Home Cellular Work Other
Unlisted?
Yes
No
2nd Phone (_______) ___________________ Home Cellular Work Other
Relationship to Student ____________________________________ 2.) Name _____________________________________
LAST
_________________________________
FIRST (Circle One) (Circle One) (Circle One)
____________________
MIDDLE
1st
Phone (_______) ___________________
Home Cellular Work Other Home Cellular Work Other
Unlisted?
Yes
No
2nd Phone (_______) ___________________ Home Cellular Work Other 3rd Phone (_______)___________________
Relationship to Student ____________________________________ 3.) Name _____________________________________
LAST
_________________________________
FIRST (Circle One) (Circle One) (Circle One)
____________________
MIDDLE
1st Phone (_______) ___________________ Home Cellular Work Other 2nd Phone (_______) ___________________ Home Cellular Work Other 3rd Phone (_______) ___________________ Home Cellular Work Other
Unlisted?
Yes
No
Relationship to Student ____________________________________
Adopted 06/22/2009