Academy of American Studies Emergency Contact Survey
Please fill out the survey with the most up to date information
Email *
Last name *
First name *
Student Osis *
Gender *
Birthday *
MM
/
DD
/
YYYY
Address *
Town *
Zip Code *
Home # *
Student Email address *
Student cell phone number *
Parent # 1 *
Parent # *
Parent Email address *
Parent # 2
Parent/Guardian #1--the student lives with me *
Parent/Guardian #2--Full Name *
Parent/Guardian #2--Cell phone number *
Parent/Guardian #2--Email *
Parent/Guardian #2--other contact information
Parent/Guardian #2--the student lives with me *
Preferred home language *
Name of Primary Care Physician, Practice or Clinic *
Physician's phone number *
List any health condition that may affect student participation in physical activities *
List any allergies or medical conditions *
Has you child received 504 Services in the past 2 years? *
List below the names, phone numbers, and relationships to the student of 3 persons who may be called in case of emergency or if your child is sick in school *
If there is a person who MAY NOT HAVE ACCESS to the student, please indicate their name, relationship to the student, and if there is an order of protection *
If none of the name contacts can be reach, what do you wish the school to do if your child is sick or injured?  NOTE:  It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail.  The recommendation of the parent as indicated above will be respected as far as possible. *
Please list the full names of your child's siblings and their schools of attendance. *
Health insurance information *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of NYC Department of Education. Report Abuse
Google Forms