NACP: Emergency Information Form 2021-2022

Emergency Information Form 2021-2022
Family Name
Select No of Students for Enrollment*

1234
Student Information/Información del Estudiante:
Student 1 Information/Información del Estudiante:
Student 1 Name*

First Name/Primer NombreMiddle Name/Segundo NombreLast Name/Apellido
Gender/Genero*

Male/MasculinoFemale/Femenino
Student’s Date of Birth/Fecha de Nacimiento del Estudiante*

MonthDayYear
Date
Grade-Level for 2021-2022 school year/Nivel de Grado para 2021-2022 año escolar*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Student Lives with:*

Both ParentsMomDadGuardianFoster Parent
Student 2 Information/Información del Estudiante:
Student 2 Name*

First NameMiddle NameLast Name
Gender/Genero*

MaleFemale
Student’s Date of Birth*

MonthDayYear
Date
Grade-Level for 2021-2022 school year*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Student Lives with:*

Both ParentsMomDadGuardianFoster Parent
Student 3 Information/Información del Estudiante:
Student 3 Name / Nombre*

First Name/Primer NombreMiddle Name/Segundo NombreLast Name/Apellido
Gender/Genero*

Male/MasculinoFemale/Femenino
Student’s Date of Birth/Fecha de Nacimiento del Estudiante*

MonthDayYear
Date
Grade-Level for 2021-2022 school year/Nivel de Grado para 2021-2022 año escolar*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Student Lives with:*

Both ParentsMomDadGuardianFoster Parent
Student 4 Information/Información del Estudiante:
Student 4 Name / Nombre*

First Name/Primer NombreMiddle Name/Segundo NombreLast Name/Apellido
Gender/Genero*

Male/MasculinoFemale/Femenino
Student’s Date of Birth/Fecha de Nacimiento del Estudiante*

MonthDayYear
Date
Grade-Level for 2021-2022 school year/Nivel de Grado para 2021-2022 año escolar*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Student Lives with:*

Both ParentsMomDadGuardianFoster Parent
Please List the Siblings in the school:
Name 1

First NameLast Name
Name 2

First NameLast Name
In case of an accident, illness, earthquake or major disaster, please list three people must be (18 years or older) who have transportation and are willing to pick up your child from school (MUST BE LOCAL). Your child will not be released to anyone except those people listed on this card. Person must bring photo I.D in order for your child to be released to them:
Emergency Contact Name 1

First NameLast Name
Relationship
Home Phone
Cell Phone
Emergency Contact Name 2

First NameLast Name
Relationship
Home Phone
Cell Phone
Emergency Contact Name 3

First NameLast Name
Relationship
Home Phone
Cell Phone
Special Health Conditions(Talking medication, allergies, etc)
Special Legal Information: (Court Order, etc.)
Authorization for emergency medical treatment
I hereby authorizes the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical orsurgical diagnosis, treatment, and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood thatthis authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to N.E.W. Academy CanogaPark to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. Thisauthorization is given in accordance with Section 49407 of the California Education Code, and shall remain effective until revoked in writing and deliveredto the District. I understand that N.E.W. Academy Canoga Park, its officers and its employees assume no liability of any nature in relation to thetransportation of the student. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatmentprovided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian.
HEALTH ALERTS - List any medical condition which restricts physical activity or requires special attention. Include conditions such as asthma and allergies such as peanut andbee stings. If none, please indicate “none”.
Does the students have health Insurance?

YesNo
If Yes,

Private Health InsuranceMedi-CalHealthy Families
Medi-Cal/Healthy Families ID Number
Private Health Insurance Name:
Group No.
Private Health Insurance Name:
Group No.
Name of Doctor / Medical Office

First NameLast Name
Phone Number of Doctor / Medical Office
Address of Doctor / Medical Office

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CERTIFY THAT I HAVE READ AND UNDERSTOOD THIS FORM AND DO HEREBY GIVE MY AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, AND THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT.
Parent/Legal Guardian's Signature*

Clear
Date

MonthDayYear
Date
Submitter's E-mail*
example@example.com
Should be Empty:

Emergency Information Form 2021-2022

Student Information/Información del Estudiante: