Family Emergency Contact

Dear Parent/Guardian:

Please complete and return to school as soon as possible.  It is very important to keep our records up-to-date and provides us with the proper procedure you wish us to take if emergency care is needed for your child(ren).  If any changes occur during the course of the school year, please call the school office with new information.

Student________________________________                                                                                  Birthdate___________

Student________________________________                                                                                  Birthdate___________

Student________________________________                                                                                  Birthdate___________

Student________________________________                                                                                  Birthdate___________

Parent/Guardian information:

Mother_________________________________                                                                      Father_____________________________

Address_______________________________                                                                                 ______________________________________

Home Phone____________________________                                                                                   ___________________________________

Work Phone______________________________                                                                         _________________________________________

Cell Phone__________________________                                                                                    ________________________________________

Physician’s Name & Phone_________________________________________________________________

Dentist’s Name & Phone___________________________________________________________________

Please list any allergies or special needs your child(ren) may have which we are not aware:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Person(s) who will care for child(ren) in case a parent cannot be reached:

Name_______________________________                                                  Phone_______________________________

Name_______________________________                                                 Phone_______________________________

**Parent permission to give Tylenol:

In the event of bad weather, listen to KBMW – 1450 AM for early dismissal and have arrangements made for young children to have a safe place to go if a responsible person will not be available at your home.  Please call the school immediately if your children are to be cared for at another home so we can inform the bus drivers.  Thank you.

THE CAMPBELL-TINTAH SCHOOL DISTRICT DOES NOT DISCRIMINATE ON

THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, AGE OR DISABILITY.

“AN EQUAL OPPORTUNITY EMPLOYER”