Emergency CardChild’s Name* First Last Birthdate* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Parent/Guardian 1 Name* First Last P1 Relationship* Parent/Guardian 1 Address* Same as child's Street Address City State / Province / Region ZIP / Postal Code P1 Phone: HomeP1 Phone: WorkP1 Phone: Cell*P1 Primary Email* Parent/Guardian 2 Name First Last P2 Relationship Parent/Guardian 2 Address Same as child's Street Address City State / Province / Region ZIP / Postal Code P2 Phone: HomeP2 Phone: WorkP2 Phone: CellP2 Primary Email Emergency Contacts (also authorized to pick up your child):Emergency Contact #1*NameAddressPhoneEmergency Contact #2*NameAddressPhoneEmergency Contact #3NameAddressPhoneList all others authorized to pick up your child from The Way of the Shepherd:Authorized Person #1NameAddressPhoneAuthorized Person #2NameAddressPhoneAuthorized Person #3NameAddressPhoneMedical CarePhysician*NameAddressPhoneDentist*NameAddressPhoneHealth Insurance InformationInsuranceInsurance Company NameMember ID#Group # We choose not to disclose our family’s Health Insurance information. Does this student have any allergies?*No AllergiesYes, my child has allergies(If yes, please complete the Allergy Documentation)Severe Allergies (reactions that could be life threatening)*NoYesCause(s) of Severe Allergy?* What is/are the reaction(s)? (Severe Allergy)* Mild Allergies (reactions that may require a doctor visit or result in missed school)*NoYesCause(s) of Mild Allergy?* What is/are the reaction(s)? (Mild Allergy)* Sensitivities (reactions that do not require a doctor visit or result in missed school)*NoYesCause(s) of Sensitivity?* What is/are the reaction(s)? (Sensitivities)* Significant Medical Information – Complete each year. Additionally, please use the Allergy Documentation Form for allergies and food sensitivities.Please check the box beside the statement:* I give permission to The Way of the Shepherd Catholic Montessori School staff to make whatever emergency measures are judged necessary for the care and protection of my child while under the supervision of the school. In case of a medical emergency, I understand that my child will be transported to the nearest medical facility by the local emergency unit for treatment, at my expense, if the local emergency resource (Police, Paramedics) deems it necessary. I hereby authorize The Way of the Shepherd Catholic Montessori School staff to act on my behalf in case of an emergency. Parent’s SignatureDate MM slash DD slash YYYY
