Contact us!

We respect your privacy and will not sell or loan your contact information.

Name *
Name

302 Vanderbilt Street
Brooklyn, NY, 11218
United States

(718) 435 2840

A Community of Learners

COPY of Emergency Contact and Health Information Form

Student's Name *
Student's Name
DOB *
DOB
Cell Phone *
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Address
Address
Parent/Guardian #2
Parent/Guardian #2
Cell Phone
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Address
Address
Emergency Contacts
Please list below the three(3) people who may be called in case of emergency or if your child is sick in school
Name *
Name
Phone Number *
Phone Number
Name #2 *
Name #2
Phone Number *
Phone Number
Name #3 *
Name #3
Phone Number *
Phone Number
If there is a person who may NOT HAVE ACCESS to child, please indicate:
If there is a person who may NOT HAVE ACCESS to child, please indicate:
Order of Protection Exists?
Administration will be notified in writing of any changes to information on this form *
Administration will be notified in writing of any changes to information on this form
By printing your name you are agreeing and singing to the above.
Health Information
It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.
Sibling #1
Sibling #1
Sibling #2
Sibling #2
Sibling #3
Sibling #3