St. Mary’s Catholic School

Student Enrollment Emergency Card

Student’s Name(s):______________________________________Grade:________Birthdate:_______

                ______________________________________Grade:________Birthdate:_______

                ______________________________________Grade:________Birthdate:_______

Parents Names and Address:

_________________________________________________________________________________________

Home phone:___________________Work phone: _________________   ______________

                                                                                            Mother                  Father

Cell phone numbers: _________________   ________________   __________________

                                              Mother                    Father              Other (specify name)

Do you give permission for your name and phone number(s) to be released to other families in the school: 

 YES___________   NO___________

Emergency Contact(s) other than parents:

_________________________________________Phone #____________________________ _________________________________________Phone #____________________________

I,________________________________________, hereby give my consent for emergency treatment for _____________________________________________________

                                                  Name of student(s)

_____________________________at ______________________________________ Hospital.

Family Doctor______________________________________Phone#___________________

List any health concerns your child may have:__________________________________

____________________________________________________________________________ 

Additional authorized persons who may pick student up from school:

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Name:____________________________________________Relationship:_______________

Signature:_________________________________________________Date:______________