Unity Lutheran Christian Elementary School Emergency Information

(One form must be completed for each student)

URL

This field is for validation purposes and should be left unchanged.

Student Name(Required)

Grade

Parent/Guardian Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Cell

Father’s Work Phone

Cell

Mother’s Work Phone

Cell

Special health considerations

If we are unable to reach you, please list the names and contact information of individuals authorized to manage emergencies on your behalf:

1) Name

Phone

Relationship

2) Name

Phone

Relationship

3) Name

Phone

Relationship

Family Doctor

Phone

Name of Hospital

Phone

If neither I nor my emergency contacts can be reached, I give permission to Unity Lutheran Christian Elementary School to seek emergency medical care for my child, including calling an ambulance or other emergency responders if needed. I understand that any related costs are my responsibility and not that the responsibility of Unity Lutheran Christian Elementary School.

Parent/Guardian Signature