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Form #1 of 3
Emergency Contact Form
Student's Last Name
Student's First Name
Middle Initial
Grade Level
Math Comprehension
Reading Comprehension
Favorite Subject
Birthday
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Charter School (or Private)
# of Siblings Attending
Parent Name #1
Phone
Parent's Email
Parent Name #2
Phone
Parent's Email
Address
City
State
Zipcode
Emergency Contact
Phone
Relationship to Student
Medical Insurance
Policy Number
Primary Doctor
Allergies / Other Medical Concerns
Fears / Apprehensions
Download Parent Waiver/Release of Liability
I have read and agree to the terms & conditions of the 'Parent Waver/Release of Liability'
Your Signature
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Signer's Printed Name
Today's Date
*
required
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