Family Name: __________________________________ Home Phone: _________________________

Child (ren's) Name:

________________________________________     ______________________________________

________________________________________     ______________________________________

Home Address: ___________________________________________________________________

Parent/Guardian Business Address: __________________________________________________

Work Phone: __________________________________ Beeper: ___________________________

If a parent or guardian cannot be reached in case of emergency, please contact the following:

1st Name: ______________________________ Phone: __________________________________

Address: ________________________________________________________________________

2nd Name: ______________________________ Phone: __________________________________

Address: _________________________________________________________________________

Family Doctor's Name: _______________________ Phone: __________________________________

In case of ambulance transport - students will be taken to Good Samaritan Hospital in Suffern, NY.

The following person(s) may pick up my child(ren) _________________________________________

___________________________________________________________________________________

In case of emergency, your child(ren) will only be released to persons listed above.

The following person(s) may NOT pick up my child(ren) _____________________________________

___________________________________________________________________________________

Please indicate any EMERGENCY MEDICAL information that we should know below:

Name:____________________________ Condition:_________________________________________

____________________________________________________________________________________

Parent/Guardian Signature: _____________________________________ Date: __________________