Emergency Procedure Form - St. Anne's Catholic School

Please fill in all blanks

Student’s Name: Last First Nickname

Father's Name Mother's Name

Phone: Cell Phone: Pager Number:

Address:

In case of an emergency, illness, or accident to the student named above, St. Anne's Catholic School personnel are authorized to proceed as indicated below:

Parent or Guardian: Number each item below 1, 2, 3, etc. in order of desired action to be taken.

Contact Mother at (location)

Phone: Cell Phone: Pager Number:

Address:

Contact Father at (location)

Phone: Cell Phone: Pager Number:

Address:

Contact family physician at (location)

Phone: Cell Phone: Pager Number:

Address:

Take student to emergency room at hospital

Address:

Other desired procedures:

Any known allergies/chronic physical problems/pertinent developmental or special accommodations needed:

Date of last tetanus shot:

Person(s)who have authorization to pick up child if parents cannot be reached.

Your child will be released only to those listed below.

Name: Phone: Relationship:

Address:

Name: Phone: Relationship:

Address:

Signature of Parent or Guardian Date:

Please print out and return this form to the school: St. Anne's Catholic School, 300 Euclid Avenue, Bristol, Virginia 24201